Provider Demographics
NPI:1497189864
Name:MCPHERSON MEDICAL & DIAGNOSTIC, LLC
Entity Type:Organization
Organization Name:MCPHERSON MEDICAL & DIAGNOSTIC, LLC
Other - Org Name:GIDEON MEDICAL CENTER-MMD
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-695-2181
Mailing Address - Street 1:PO BOX 12545
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4016
Mailing Address - Country:US
Mailing Address - Phone:573-448-3800
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GIDEON
Practice Address - State:MO
Practice Address - Zip Code:63848-9253
Practice Address - Country:US
Practice Address - Phone:573-448-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCPHERSON MEDICAL & DIAGNOSTIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-21
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9E31207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA10540Medicare UPIN