Basic Information
| Provider Information | |||||||||
| NPI: | 1548456866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEAD AND NECK SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 FOREST AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077975753 | ||||||||
| FaxNumber: | 2078181715 | ||||||||
| Practice Location | |||||||||
| Address1: | 244 KENNEDY MEMORIAL DR | ||||||||
| Address2: | SUITE G | ||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049014538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078721937 | ||||||||
| FaxNumber: | 2078721949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 09/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | BUTLAND | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2077975753 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEAD AND NECK SURGICAL ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0905X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
No ID Information.