1407897614 NPI number — SHANNON MARIE MEREDITH DPM

Table of content: SHANNON MARIE MEREDITH DPM (NPI 1407897614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407897614 NPI number — SHANNON MARIE MEREDITH DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEREDITH
Provider First Name:
SHANNON
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1407897614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
144 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04101-3776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-879-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
195 FORE RIVER PKWY
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04102-2780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-553-6682
Provider Business Practice Location Address Fax Number:
207-553-6681
Provider Enumeration Date:
06/09/2006

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: 213E00000X , with the licence number:  1000 , 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: 014284 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 104104 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 480016606 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 127440000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14284 . This is a "FEDERAL BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: U47765 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 001299 . This is a "MARTINS POINT" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 100429800 . This is a "DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com