Provider Demographics
NPI:1811100068
Name:NEUROPSYCHOLOGY SERVICE PA
Entity type:Organization
Organization Name:NEUROPSYCHOLOGY SERVICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROYAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:GRUENEICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:207-990-2580
Mailing Address - Street 1:277 STATE ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5439
Mailing Address - Country:US
Mailing Address - Phone:207-990-2580
Mailing Address - Fax:207-990-1930
Practice Address - Street 1:277 STATE STREET
Practice Address - Street 2:SUITE 2A
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5440
Practice Address - Country:US
Practice Address - Phone:207-990-2580
Practice Address - Fax:207-990-1930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5418635OtherAETNA
P0724OtherANTHEM
NEMM7057Medicare ID - Type Unspecified