Provider Demographics
NPI:1225018740
Name:WATERBORO VILLAGE PEDIATRICS LLC PA
Entity Type:Organization
Organization Name:WATERBORO VILLAGE PEDIATRICS LLC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEASHA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:MARESCOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-247-6742
Mailing Address - Street 1:PO BOX 1849
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1849
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-5363
Practice Address - Street 1:43 SOKOKIS TRAIL
Practice Address - Street 2:
Practice Address - City:EAST WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04030
Practice Address - Country:US
Practice Address - Phone:207-247-6742
Practice Address - Fax:207-247-6114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30213870Medicaid
ME157150000Medicaid