Provider Demographics
NPI:1043297179
Name:MAINE OTOLARYNGOLOGY SURGERY
Entity type:Organization
Organization Name:MAINE OTOLARYNGOLOGY SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-338-4409
Mailing Address - Street 1:116 NORTHPORT AVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6095
Mailing Address - Country:US
Mailing Address - Phone:207-338-4409
Mailing Address - Fax:207-338-4486
Practice Address - Street 1:116 NORTHPORT AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6095
Practice Address - Country:US
Practice Address - Phone:207-338-4409
Practice Address - Fax:207-338-4486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015045174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME189920000Medicaid
CG7643Medicare PIN
ME189920000Medicaid