Provider Demographics
NPI:1043374044
Name:MOUSAM VALLEY ORTHOPAEDICS PA
Entity Type:Organization
Organization Name:MOUSAM VALLEY ORTHOPAEDICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEBAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-324-1488
Mailing Address - Street 1:312 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-1828
Mailing Address - Country:US
Mailing Address - Phone:207-324-1488
Mailing Address - Fax:207-490-5733
Practice Address - Street 1:312 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-1828
Practice Address - Country:US
Practice Address - Phone:207-324-1488
Practice Address - Fax:207-490-5733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0804370001Medicare NSC
MEMM5576Medicare ID - Type Unspecified