1073045308 NPI number — ALICE E SHALLCROSS DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073045308 NPI number — ALICE E SHALLCROSS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHALLCROSS
Provider First Name:
ALICE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073045308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1599
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04402-1599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-404-8100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
242 BRUNSWICK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLD TOWN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04468-1613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-827-6128
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS16738 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: DO3691 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106254100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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