Basic Information
| Provider Information | |||||||||
| NPI: | 1205150323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN MAINE MULTI-MEDICAL SPECIALISTS | ||||||||
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| OtherOrganizationName: | WESTERN MAINE FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 US ROUTE 1 | ||||||||
| Address2: | BUILDING C | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 2073968632 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 WINTER ST | ||||||||
| Address2: | |||||||||
| City: | NORWAY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042685620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077438031 | ||||||||
| FaxNumber: | 2077436672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2010 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VP FISCAL | ||||||||
| AuthorizedOfficialTelephone: | 2077439292 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 127080103 | 05 | ME | MEDICAID | 127080007 | 05 | ME | MEDICAID |