Basic Information
| Provider Information | |||||||||
| NPI: | 1386634707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERVILLE FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 RAILROAD SQ | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049016139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078731181 | ||||||||
| FaxNumber: | 2078731186 | ||||||||
| Practice Location | |||||||||
| Address1: | 13 RAILROAD SQ | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049016139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078731181 | ||||||||
| FaxNumber: | 2078731186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUREAU | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2078731181 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.