Provider Demographics
NPI:1598945321
Name:MACKLIN & ERVIN MDPA
Entity Type:Organization
Organization Name:MACKLIN & ERVIN MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:DOLE
Authorized Official - Last Name:ERVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-873-6183
Mailing Address - Street 1:2 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-7518
Mailing Address - Country:US
Mailing Address - Phone:207-873-6183
Mailing Address - Fax:207-861-5457
Practice Address - Street 1:2 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-7518
Practice Address - Country:US
Practice Address - Phone:207-873-6183
Practice Address - Fax:207-861-5457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME010650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107850099Medicaid
MEB86533Medicare UPIN
ME107850099Medicaid