Basic Information
| Provider Information | |||||||||
| NPI: | 1124084975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINEGENERAL HEALTH ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WINTHROP FAMILY PEDIATRICS AND ADOLESCENTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 DRESDEN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDINER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043452615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076219337 | ||||||||
| FaxNumber: | 2076213609 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 MAIN ST | ||||||||
| Address2: | SUITE 1A | ||||||||
| City: | WINTHROP | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043641486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073772114 | ||||||||
| FaxNumber: | 2073776112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | CROWLEY | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, MGHA | ||||||||
| AuthorizedOfficialTelephone: | 2076261063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 164570011 | 05 | ME | MEDICAID |