Basic Information
| Provider Information | |||||||||
| NPI: | 1568645869 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PAIN MANAGEMENT CENTER OF MIDCOAST MAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 810 | ||||||||
| Address2: | |||||||||
| City: | WESTBROOK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040980810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078541544 | ||||||||
| FaxNumber: | 2078541516 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 BATH RD | ||||||||
| Address2: | |||||||||
| City: | WISCASSET | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078821113 | ||||||||
| FaxNumber: | 2078821114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2007 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | KAZALSKI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DO OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2078821113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 1767 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 262680000 | 05 | ME | MEDICAID | 1912059353 | 01 | ME | INDIVIDUAL NPI # | OTHER |