Provider Demographics
NPI:1104007368
Name:WAREHAM NURSE MIDWIVES PC
Entity Type:Organization
Organization Name:WAREHAM NURSE MIDWIVES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:RACINE
Authorized Official - Last Name:BASTARACHE
Authorized Official - Suffix:
Authorized Official - Credentials:CNM MS NP
Authorized Official - Phone:508-295-3088
Mailing Address - Street 1:332 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571
Mailing Address - Country:US
Mailing Address - Phone:508-295-3088
Mailing Address - Fax:508-295-2079
Practice Address - Street 1:332 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571
Practice Address - Country:US
Practice Address - Phone:508-295-3088
Practice Address - Fax:508-295-2079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA143429176B00000X, 363L00000X
MA275550367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9783571Medicaid
MANC0012OtherBCBS
RC0002Medicare PIN