Provider Demographics
NPI:1316043276
Name:WESTERN MAINE MULTI-MEDICAL SPECIALIST
Entity Type:Organization
Organization Name:WESTERN MAINE MULTI-MEDICAL SPECIALIST
Other - Org Name:WESTERN MAINE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-743-9292
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5645
Practice Address - Country:US
Practice Address - Phone:207-743-9292
Practice Address - Fax:207-743-1578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM5793Medicare ID - Type Unspecified