Basic Information
Provider Information | |||||||||
NPI: | 1154399905 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAUGHAN | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | YORK | ||||||||
State: | ME | ||||||||
PostalCode: | 039091011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073513455 | ||||||||
FaxNumber: | 2073513461 | ||||||||
Practice Location | |||||||||
Address1: | 16 HOSPITAL DR | ||||||||
Address2: | STE C. | ||||||||
City: | YORK | ||||||||
State: | ME | ||||||||
PostalCode: | 039091011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073513455 | ||||||||
FaxNumber: | 2073513454 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/09/2006 | ||||||||
LastUpdateDate: | 10/29/2013 | ||||||||
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 | 207V00000X | 0101050803 | VA | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | MD17375 | ME | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 1154399905 | 05 | ME |   | MEDICAID | 236908 | 01 |   | UHC/MAMSI | OTHER | PAR | 01 | VA | CIGNA | OTHER | -010 | 01 | VA | TRICARE/CHAMPUS | OTHER | 006207359 | 05 | VA |   | MEDICAID | PAR | 01 | VA | USA MANAGED CARE | OTHER | 0633B | 01 | NC | NC BC/BS | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | 320762 | 01 | VA | ANTHEM | OTHER | PAR | 01 | VA | AETNA | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | 14067 | 01 | VA | SENTARA OPTIMA | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | PAR | 01 | VA | FIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY | OTHER | 890633B | 05 | NC |   | MEDICAID | 1154399905 | 05 | VA |   | MEDICAID |