Provider Demographics
NPI:1235204157
Name:MILES MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MILES MEMORIAL HOSPITAL
Other - Org Name:MMG PEDIATRICS-BOOTHBAY A DEPARTMENT OF MILES MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-563-4780
Mailing Address - Street 1:PO BOX 745
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:ME
Mailing Address - Zip Code:04553-0745
Mailing Address - Country:US
Mailing Address - Phone:207-633-1182
Mailing Address - Fax:207-633-1183
Practice Address - Street 1:137B TOWNSEND AVE
Practice Address - Street 2:
Practice Address - City:BOOTHBAY HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04538
Practice Address - Country:US
Practice Address - Phone:207-633-1182
Practice Address - Fax:207-633-1183
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILES MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36774207V00000X, 208000000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200002Medicare PIN