Provider Demographics
NPI:1134207160
Name:STOLLER, DIANE K
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:K
Last Name:STOLLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 STATE STREET
Mailing Address - Street 2:MERCY HOSPITAL
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 STATE STREET
Practice Address - Street 2:MERCY HOSPITAL
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3795
Practice Address - Country:US
Practice Address - Phone:207-553-6808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30027208600000X
MEMD21011282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN04Q32STOtherBLUE CROSS BLUE SHIELD
MN154585000Medicaid
MN020000996Medicare PIN
MN04Q32STOtherBLUE CROSS BLUE SHIELD