Basic Information
| Provider Information | |||||||||
| NPI: | 1982682191 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENNEBEC VALLEY OBSTETRICS & GYNECOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 CALDWELL RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076231322 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 CALDWELL RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076231322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2076231322 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 3173496 | 01 | ME | CIGNA | OTHER | C0101 | 01 | ME | ANTHEM | OTHER |