Provider Demographics
NPI:1013185826
Name:ELLEN M ANDERSON DPM
Entity Type:Organization
Organization Name:ELLEN M ANDERSON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-564-2536
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-0327
Mailing Address - Country:US
Mailing Address - Phone:207-564-2536
Mailing Address - Fax:207-564-8581
Practice Address - Street 1:839 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1334
Practice Address - Country:US
Practice Address - Phone:207-564-2536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD 155332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME112960000Medicaid
1349170001Medicare NSC
ME112960000Medicaid
015197Medicare PIN