Provider Demographics
NPI:1184709495
Name:PEDIATRIC ASSOCIATES OF LEWISTON P.A.
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF LEWISTON P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-784-5782
Mailing Address - Street 1:33 MOLLISON WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5805
Mailing Address - Country:US
Mailing Address - Phone:207-784-5782
Mailing Address - Fax:207-786-5756
Practice Address - Street 1:33 MOLLISON WAY
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5805
Practice Address - Country:US
Practice Address - Phone:207-784-5782
Practice Address - Fax:207-786-5756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME134370000Medicaid