Basic Information
| Provider Information | |||||||||
| NPI: | 1356578272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIDELOCK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WAYMAN LN | ||||||||
| Address2: | MDI HOSPITAL | ||||||||
| City: | BAR HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046091625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072885082 | ||||||||
| FaxNumber: | 2072888600 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 WAYMAN LN | ||||||||
| Address2: | MDI HOSPITAL | ||||||||
| City: | BAR HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046091625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072885082 | ||||||||
| FaxNumber: | 2072888600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 03/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TD 121060 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 250421 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.