Basic Information
| Provider Information | |||||||||
| NPI: | 1124130638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARRACHE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 SILVER ST | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078720866 | ||||||||
| FaxNumber: | 2078728098 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 SILVER ST | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078720866 | ||||||||
| FaxNumber: | 2078728098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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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 | 207Q00000X | 015761 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 132890099 | 05 | ME | MEDICAID | 027974 | 01 | ME | ANTHEM | OTHER |