Provider Demographics
NPI:1760600803
Name:STOREYSMITH PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:STOREYSMITH PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:STOREYSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:207-829-8007
Mailing Address - Street 1:85 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3707
Mailing Address - Country:US
Mailing Address - Phone:207-829-8007
Mailing Address - Fax:207-829-8008
Practice Address - Street 1:85 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:ME
Practice Address - Zip Code:04021-3707
Practice Address - Country:US
Practice Address - Phone:207-829-8007
Practice Address - Fax:207-829-8008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP667235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME23494099Medicaid