Basic Information
Provider Information | |||||||||
NPI: | 1437358157 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DERSCH | ||||||||
FirstName: | CANDICE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 US ROUTE 1 | ||||||||
Address2: | BUILDING C | ||||||||
City: | SCARBOROUGH | ||||||||
State: | ME | ||||||||
PostalCode: | 040749701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073968600 | ||||||||
FaxNumber: | 2073968632 | ||||||||
Practice Location | |||||||||
Address1: | 887 CONGRESS ST | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041023166 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077715549 | ||||||||
FaxNumber: | 2077717834 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2007 | ||||||||
LastUpdateDate: | 08/03/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD18808 | ME | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 32000563 | 05 | NH |   | MEDICAID |