Basic Information
| Provider Information | |||||||||
| NPI: | 1295820652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. ANDREWS HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. ANDREWS HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 417 | ||||||||
| Address2: | |||||||||
| City: | BOOTHBAY HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045380417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076331919 | ||||||||
| FaxNumber: | 2076331224 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 ST. ANDREWS LANE | ||||||||
| Address2: | |||||||||
| City: | BOOTHBAY HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045380417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076331919 | ||||||||
| FaxNumber: | 2076331224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRINTY | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2076338413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 2754 | ME | Y | Agencies | Home Health |
No ID Information.