Basic Information
| Provider Information | |||||||||
| NPI: | 1316043276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN MAINE MULTI-MEDICAL SPECIALIST | ||||||||
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| OtherOrganizationName: | WESTERN MAINE FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 WALLACE AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077610650 | ||||||||
| FaxNumber: | 2077618198 | ||||||||
| Practice Location | |||||||||
| Address1: | 193 MAIN ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | NORWAY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042685645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077439292 | ||||||||
| FaxNumber: | 2077431578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2077439292 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.