Basic Information
| Provider Information | |||||||||
| NPI: | 1346706629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALAIS REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EASTPORT PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 24 HOSPITAL LN | ||||||||
| Address2: | |||||||||
| City: | CALAIS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046191329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074547521 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 BOYNTON ST | ||||||||
| Address2: | |||||||||
| City: | EASTPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046311306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074547521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2019 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARNETT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2074549253 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CALAIS REGIONAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.