Basic Information
Provider Information | |||||||||
NPI: | 1184810400 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEAD AND NECK SURGICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1250 FOREST AVE | ||||||||
Address2: | SUITE 301 | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041031889 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077975753 | ||||||||
FaxNumber: | 2078781715 | ||||||||
Practice Location | |||||||||
Address1: | 1250 FOREST AVE | ||||||||
Address2: | SUITE 301 | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041031889 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077975753 | ||||||||
FaxNumber: | 2078781715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2007 | ||||||||
LastUpdateDate: | 09/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUTLAND | ||||||||
AuthorizedOfficialFirstName: | ELAINE | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2077975753 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HEAD AND NECK SURGICAL ASSOCIATES | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
No ID Information.