Basic Information
Provider Information | |||||||||
NPI: | 1275615551 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICCIONI | ||||||||
FirstName: | MARCUS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 174 S FREEPORT RD | ||||||||
Address2: |   | ||||||||
City: | FREEPORT | ||||||||
State: | ME | ||||||||
PostalCode: | 040326145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078651819 | ||||||||
FaxNumber: | 2078654535 | ||||||||
Practice Location | |||||||||
Address1: | 123 MEDICAL CENTER DR | ||||||||
Address2: |   | ||||||||
City: | BRUNSWICK | ||||||||
State: | ME | ||||||||
PostalCode: | 040112652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077290181 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 10/30/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 013669 | ME | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | F72448 | 01 | ME | HARVARD PILGRIM HEALTHCAR | OTHER | 2421688 | 01 | ME | AETNA | OTHER | 099877 | 01 | ME | ANTHEM | OTHER | 8561900 | 01 | ME | CIGNA | OTHER |