Basic Information
| Provider Information | |||||||||
| NPI: | 1548355654 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILES MEMORIAL HOSPITAL INCORPORATED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MILES MEMORIAL HOSPITAL SWING BED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 539 | ||||||||
| Address2: | |||||||||
| City: | WEST BOOTHBAY HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045750539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075631234 | ||||||||
| FaxNumber: | 2076331224 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MILES ST | ||||||||
| Address2: | |||||||||
| City: | DAMARISCOTTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045434047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075631234 | ||||||||
| FaxNumber: | 2076331224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 02/23/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRINTY | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2075634476 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MILES MEMORIAL HOSPITAL INCORPORATED | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 36359 | ME | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 101980000 | 05 | ME | MEDICAID |