Basic Information
| Provider Information | |||||||||
| NPI: | 1598945321 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACKLIN & ERVIN MDPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 SCHOOL ST | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049017518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736183 | ||||||||
| FaxNumber: | 2078615457 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SCHOOL ST | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049017518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736183 | ||||||||
| FaxNumber: | 2078615457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | ERVIN | ||||||||
| AuthorizedOfficialFirstName: | EDMUND | ||||||||
| AuthorizedOfficialMiddleName: | DOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2078736183 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 010650 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 107850099 | 05 | ME | MEDICAID |