Basic Information
| Provider Information | |||||||||
| NPI: | 1295905271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEBASTICOOK MEDICAL SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 810 | ||||||||
| Address2: | |||||||||
| City: | WESTBROOK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040980810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078541544 | ||||||||
| FaxNumber: | 2078541516 | ||||||||
| Practice Location | |||||||||
| Address1: | 470 STATE STREET | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079734878 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2008 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | EDGAR | ||||||||
| AuthorizedOfficialFirstName: | EMILY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PATIENT ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 2074870916 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | HX3558 | 01 | ME | MEDICARE INDIVIDUAL NUMBE | OTHER |