Provider Demographics
NPI:1326191859
Name:LYMPHEDEMA ASSOC OF MAINE
Entity Type:Organization
Organization Name:LYMPHEDEMA ASSOC OF MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DEVEREUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-487-4966
Mailing Address - Street 1:PO BOX 522
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04967-0522
Mailing Address - Country:US
Mailing Address - Phone:207-487-4966
Mailing Address - Fax:207-487-4966
Practice Address - Street 1:715 HIGGINS ROAD
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:ME
Practice Address - Zip Code:04967-0522
Practice Address - Country:US
Practice Address - Phone:207-487-4966
Practice Address - Fax:207-487-4966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
12Z050223ME01OtherANTHEM BLUE CROSS/BLUE SH
MEAA57491OtherHARVARD PILGRIM
ME7944648OtherAETNA
ME050223OtherBCBS
ME7944648OtherAETNA