Basic Information
Provider Information | |||||||||
NPI: | 1114212149 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SILCO | ||||||||
FirstName: | MICHAELA | ||||||||
MiddleName: | O. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | O'ROURKE | ||||||||
OtherFirstName: | MICHAELA | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 GANNETT DRIVE | ||||||||
Address2: | SUITE C | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041065900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078280361 | ||||||||
FaxNumber: | 2078741483 | ||||||||
Practice Location | |||||||||
Address1: | 100 FODEN RD, EAST | ||||||||
Address2: | SUITE 203 | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041062327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078741489 | ||||||||
FaxNumber: | 2075238590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2011 | ||||||||
LastUpdateDate: | 09/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207Q00000X | DO2430 | ME | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1114212149 | 05 | ME |   | MEDICAID |