Basic Information
Provider Information | |||||||||
NPI: | 1073585865 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOUCY | ||||||||
FirstName: | DENISE | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 68 CHAPMAN ST | ||||||||
Address2: |   | ||||||||
City: | DAMARISCOTTA | ||||||||
State: | ME | ||||||||
PostalCode: | 045434614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075636623 | ||||||||
FaxNumber: | 2075636625 | ||||||||
Practice Location | |||||||||
Address1: | 68 CHAPMAN ST | ||||||||
Address2: |   | ||||||||
City: | DAMARISCOTTA | ||||||||
State: | ME | ||||||||
PostalCode: | 045434614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075636623 | ||||||||
FaxNumber: | 2075636625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0124946 | ME | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | E52613 | 01 |   | HARVARD PILGRIM | OTHER | 060977 | 01 |   | ANTHEM | OTHER | 3378355 | 01 |   | AETNA | OTHER | 9962527 | 01 |   | CIGNA | OTHER |