Basic Information
| Provider Information | |||||||||
| NPI: | 1073579074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BICZAK | ||||||||
| FirstName: | LAUREEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GANNETT DR STE C | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 FODEN RD, STE 3 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041061718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077745816 | ||||||||
| FaxNumber: | 2075238594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1167 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 1167 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 265860099 | 05 | ME | MEDICAID | 1041404 | 01 | AETNA | OTHER | 018025 | 01 | ANTHEM | OTHER |