Provider Demographics
NPI:1730296740
Name:MULLALLY, BRIGID A (MD)
Entity Type:Individual
Prefix:
First Name:BRIGID
Middle Name:A
Last Name:MULLALLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5739
Mailing Address - Country:US
Mailing Address - Phone:207-623-1322
Mailing Address - Fax:207-623-3629
Practice Address - Street 1:5 CALDWELL RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5739
Practice Address - Country:US
Practice Address - Phone:207-623-1322
Practice Address - Fax:207-623-3629
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017243207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3539521OtherCIGNA
ME432337299Medicaid
ME098243OtherANTHEM
MEP00375036OtherRAILROAD MEDICARE
ME01 0404305OtherTAX ID
ME1290858OtherAETNA
ME3539521OtherCIGNA
MEME2131Medicare PIN
ME098243OtherANTHEM