1275588261 NPI number — LYNETTE J WEEMAN D.O.

Table of content: LYNETTE J WEEMAN D.O. (NPI 1275588261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275588261 NPI number — LYNETTE J WEEMAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEEMAN
Provider First Name:
LYNETTE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAHNESTOCK
Provider Other First Name:
LYNETTE
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275588261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301C US ROUTE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCARBOROUGH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04074-9701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-396-8600
Provider Business Mailing Address Fax Number:
207-396-8632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
198 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04240-7019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-777-5300
Provider Business Practice Location Address Fax Number:
207-777-1276
Provider Enumeration Date:
05/24/2006

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: 207RC0000X , with the licence number:  1711 , 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: 107650003 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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