Basic Information
| Provider Information | |||||||||
| NPI: | 1588823769 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH ACCESS NETWORK INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEALTH ACCESS NETWORK-WEST ENFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044570099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077946700 | ||||||||
| FaxNumber: | 2077325247 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 BRIDGE STREET | ||||||||
| Address2: | |||||||||
| City: | WEST ENFIELD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077946700 | ||||||||
| FaxNumber: | 2077325247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GLIDDEN | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | EMR MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2077946700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH ACCESS NETWORK INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.