Provider Demographics
NPI:1326058504
Name:PROCTOLOGY ASSOCIATES OF MAINE PA
Entity Type:Organization
Organization Name:PROCTOLOGY ASSOCIATES OF MAINE PA
Other - Org Name:COASTAL HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-406-2698
Mailing Address - Street 1:214A DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-7225
Mailing Address - Country:US
Mailing Address - Phone:207-406-2698
Mailing Address - Fax:207-406-2114
Practice Address - Street 1:214A DURHAM RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-7225
Practice Address - Country:US
Practice Address - Phone:207-406-2698
Practice Address - Fax:207-406-2698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM0185Medicare PIN