Basic Information
Provider Information | |||||||||
NPI: | 1285690263 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAINEGENERAL HEALTH ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KENNEBEC PEDIATRICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 150 DRESDEN AVE | ||||||||
Address2: |   | ||||||||
City: | GARDINER | ||||||||
State: | ME | ||||||||
PostalCode: | 043452615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2076219337 | ||||||||
FaxNumber: | 2076213609 | ||||||||
Practice Location | |||||||||
Address1: | 263 WATER ST | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | ME | ||||||||
PostalCode: | 043304609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2076232977 | ||||||||
FaxNumber: | 2076269374 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 10/04/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CROWLEY | ||||||||
AuthorizedOfficialFirstName: | BARBARA | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT, MGHA | ||||||||
AuthorizedOfficialTelephone: | 2076261063 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363A00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 208000000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.