Provider Demographics
NPI:1336145200
Name:NORTHEAST NEPHROLOGY PA
Entity Type:Organization
Organization Name:NORTHEAST NEPHROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:COMEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-973-8833
Mailing Address - Street 1:417 STATE ST
Mailing Address - Street 2:STE 321
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6638
Mailing Address - Country:US
Mailing Address - Phone:207-973-8833
Mailing Address - Fax:207-973-8836
Practice Address - Street 1:417 STATE ST
Practice Address - Street 2:STE 321
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6638
Practice Address - Country:US
Practice Address - Phone:207-973-8833
Practice Address - Fax:207-973-8836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME132020000Medicaid
ME132020000Medicaid