Provider Demographics
NPI:1629159298
Name:JONATHAN HERLAND D SC MD PA
Entity Type:Organization
Organization Name:JONATHAN HERLAND D SC MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:HERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-927-7246
Mailing Address - Street 1:198 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-1836
Mailing Address - Country:US
Mailing Address - Phone:855-927-7246
Mailing Address - Fax:
Practice Address - Street 1:163 VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-3567
Practice Address - Country:US
Practice Address - Phone:855-927-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015192174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME039403OtherANTHEM
ME155430000Medicaid
ME7014011OtherAETNA
MEMM8763Medicare ID - Type Unspecified