Provider Demographics
NPI:1023004496
Name:WALWORTH, EDWARD Z (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:Z
Last Name:WALWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4157
Mailing Address - Street 2:ST. MARY'S HEALTH SYSTEM
Mailing Address - City:BOSTON
Mailing Address - State:MH
Mailing Address - Zip Code:02211-4157
Mailing Address - Country:US
Mailing Address - Phone:207-777-4111
Mailing Address - Fax:207-783-6660
Practice Address - Street 1:710 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5801
Practice Address - Country:US
Practice Address - Phone:207-783-1449
Practice Address - Fax:207-777-3865
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME240490099Medicaid
ME240490099Medicaid
MEB87017Medicare UPIN