Basic Information
| Provider Information | |||||||||
| NPI: | 1285925438 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEPHENS MEMORIAL HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WESTERN MAINE SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 181 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORWAY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042685664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077435933 | ||||||||
| FaxNumber: | 2077431566 | ||||||||
| Practice Location | |||||||||
| Address1: | 193 MAIN ST | ||||||||
| Address2: | RIPLEY MEDICAL BUILDING | ||||||||
| City: | NORWAY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042685645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077437544 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2011 | ||||||||
| LastUpdateDate: | 05/16/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FISCAL | ||||||||
| AuthorizedOfficialTelephone: | 2077435933 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STEPHENS MEMORIAL HOSPITAL ASSOCIATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 37353 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.