Basic Information
| Provider Information | |||||||||
| NPI: | 1548730567 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDS COVERAGE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1778 | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042411778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073753024 | ||||||||
| FaxNumber: | 2073753026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1577 CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076621442 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2018 | ||||||||
| LastUpdateDate: | 12/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | BLUMENTHAL | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2075536300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1275565384 | 05 | ME | MEDICAID |