Basic Information
Provider Information | |||||||||
NPI: | 1821038472 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRGAN | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 105 CRESTVIEW DR | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041067800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077973006 | ||||||||
FaxNumber: | 2077973002 | ||||||||
Practice Location | |||||||||
Address1: | 74 GRAY RD | ||||||||
Address2: |   | ||||||||
City: | FALMOUTH | ||||||||
State: | ME | ||||||||
PostalCode: | 041052019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077973006 | ||||||||
FaxNumber: | 2077973002 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2542 | ME | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 5632878 | 01 |   | CCN INDIV. # | OTHER | 9992617 | 01 |   | CIGNA INDIV # | OTHER | 048646 | 01 | ME | ANTHEM ME INDIV. # | OTHER | 18874001 | 05 | ME |   | MEDICAID | 7015693 | 01 |   | AETNA PIN # | OTHER |