Basic Information
Provider Information | |||||||||
NPI: | 1477523074 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOVE | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301C US ROUTE 1 | ||||||||
Address2: |   | ||||||||
City: | SCARBOROUGH | ||||||||
State: | ME | ||||||||
PostalCode: | 040749701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073968600 | ||||||||
FaxNumber: | 2073968632 | ||||||||
Practice Location | |||||||||
Address1: | 96 CAMPUS DR | ||||||||
Address2: | SUITE 1 | ||||||||
City: | SCARBOROUGH | ||||||||
State: | ME | ||||||||
PostalCode: | 040747164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078859905 | ||||||||
FaxNumber: | 2073965600 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2006 | ||||||||
LastUpdateDate: | 12/03/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | MD11481 | ME | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | MD11481 | ME | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | MD11481 | ME | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 277740099 | 05 | ME |   | MEDICAID |