Provider Demographics
NPI:1790871994
Name:WATERVILLE PEDIATRICS PA
Entity Type:Organization
Organization Name:WATERVILLE PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-873-5437
Mailing Address - Street 1:295C KENNEDY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4535
Mailing Address - Country:US
Mailing Address - Phone:207-873-5437
Mailing Address - Fax:207-872-6037
Practice Address - Street 1:295C KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4535
Practice Address - Country:US
Practice Address - Phone:207-873-5437
Practice Address - Fax:207-872-6037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1317208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000206014Medicaid
ME129440000OtherMAINECARE PROVIDER NO.