Basic Information
| Provider Information | |||||||||
| NPI: | 1730296740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MULLALLY | ||||||||
| FirstName: | BRIGID | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 CALDWELL RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076231322 | ||||||||
| FaxNumber: | 2076233629 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 CALDWELL RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076231322 | ||||||||
| FaxNumber: | 2076233629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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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 | 207V00000X | 017243 | ME | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 3539521 | 01 | ME | CIGNA | OTHER | 432337299 | 05 | ME | MEDICAID | 098243 | 01 | ME | ANTHEM | OTHER | P00375036 | 01 | ME | RAILROAD MEDICARE | OTHER | 01 0404305 | 01 | ME | TAX ID | OTHER | 1290858 | 01 | ME | AETNA | OTHER |