Basic Information
| Provider Information | |||||||||
| NPI: | 1659367217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRALEY | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 FRANKLIN HEALTH COMMONS | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077792357 | ||||||||
| FaxNumber: | 2077792240 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 FRANKLIN HEALTH COMMONS | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077792357 | ||||||||
| FaxNumber: | 2077792240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 32682 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 32682 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | 017689 | ME | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 64326820 | 05 | KY | MEDICAID |