Basic Information
| Provider Information | |||||||||
| NPI: | 1255317897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOULDSBROUGH | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | PO BOX 626 | ||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072829080 | ||||||||
| FaxNumber: | 2079858459 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 SHAPE DRIVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | KENNEBUNK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074678930 | ||||||||
| FaxNumber: | 4679858459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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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 | 208000000X | 1395 | ME | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 242320099 | 05 | ME | MEDICAID |