Basic Information
Provider Information | |||||||||
NPI: | 1801870506 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAKARETZ | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 43 BAXTER BLVD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041011823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077756381 | ||||||||
FaxNumber: | 2077753378 | ||||||||
Practice Location | |||||||||
Address1: | 43 BAXTER BLVD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041011823 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077756381 | ||||||||
FaxNumber: | 2077753378 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2005 | ||||||||
LastUpdateDate: | 02/07/2012 | ||||||||
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 | 207YX0007X | 015663 | ME | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
ID | Type | State | Issuer | Description | 040016217 | 01 | ME | RAILROAD INDIV PROV # | OTHER | 100224700 | 01 | ME | DEPARTMENT OF LABOR | OTHER | 2628379 | 01 | ME | AETNA | OTHER | 002413 | 01 | ME | ANTHEM BLUE SHIELD | OTHER | 276630099 | 05 | ME |   | MEDICAID | CH8191 | 01 | ME | RAILROAD MCARE GROUP # | OTHER | 110570100 | 05 | ME |   | MEDICAID | 110570000 | 05 | ME |   | MEDICAID | MN4436 | 01 | ME | HARVARD PILGIRM | OTHER | 9480962 | 01 | ME | CIGNA INDIV PROV NUMBER | OTHER | M2995 | 01 | ME | CIGNA NEW HAMPSHIRE | OTHER |