Basic Information
| Provider Information | |||||||||
| NPI: | 1356348775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLANDER | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076261561 | ||||||||
| FaxNumber: | 2076261849 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 E CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076261561 | ||||||||
| FaxNumber: | 2076261849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/20/2006 | ||||||||
| NPIReactivationDate: | 04/05/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1472 | ME | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1356348775 | 05 | ME | MEDICAID | 321430099 | 05 | ME | MEDICAID |