Basic Information
Provider Information | |||||||||
NPI: | 1942403266 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEBBER HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SMMC PEDIATRICS BIDDEFORD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 39 WALLACE AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041066143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077610650 | ||||||||
FaxNumber: | 2077618198 | ||||||||
Practice Location | |||||||||
Address1: | 473 ALFRED ST | ||||||||
Address2: |   | ||||||||
City: | BIDDEFORD | ||||||||
State: | ME | ||||||||
PostalCode: | 040059447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072839031 | ||||||||
FaxNumber: | 2072849825 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2007 | ||||||||
LastUpdateDate: | 10/27/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAVOIE | ||||||||
AuthorizedOfficialFirstName: | FRANK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP MEDICAL AFFAIRS | ||||||||
AuthorizedOfficialTelephone: | 2072837000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 208000000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 30216388 | 05 | NH |   | MEDICAID | 101580000 | 05 | ME |   | MEDICAID | 432732800 | 05 | ME |   | MEDICAID |