Basic Information
| Provider Information | |||||||||
| NPI: | 1649234378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAKE | ||||||||
| FirstName: | BETHANY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DRIVE | ||||||||
| Address2: | PO BOX 626 | ||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072829080 | ||||||||
| FaxNumber: | 2072829180 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 GOODALL DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | E. WATERBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074907970 | ||||||||
| FaxNumber: | 2072829128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 12/18/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 015660 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 247150099 | 05 | ME | MEDICAID |