Basic Information
| Provider Information | |||||||||
| NPI: | 1104895747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLERDING | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WAYMAN LN | ||||||||
| Address2: | |||||||||
| City: | BAR HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046091625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072885081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 WAYMAN LN | ||||||||
| Address2: | |||||||||
| City: | BAR HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046091625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072885081 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 340004179 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | LT16010 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0640408 | 05 | OH | MEDICAID |