Provider Demographics
NPI:1063671121
Name:WILDWOOD MEDICINE
Entity Type:Organization
Organization Name:WILDWOOD MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT NC
Authorized Official - Phone:207-347-7132
Mailing Address - Street 1:PO BOX 7412
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04112
Mailing Address - Country:US
Mailing Address - Phone:207-347-7132
Mailing Address - Fax:207-839-2197
Practice Address - Street 1:83 INDIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4210
Practice Address - Country:US
Practice Address - Phone:207-347-7132
Practice Address - Fax:207-839-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC281171100000X
MEAC308171100000X
MEPT3116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty