Provider Demographics
NPI:1194058313
Name:SMALL, RONALD PHILLIP
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:PHILLIP
Last Name:SMALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:ME
Mailing Address - Zip Code:04427-0129
Mailing Address - Country:US
Mailing Address - Phone:207-285-3281
Mailing Address - Fax:
Practice Address - Street 1:316 MAIN ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:ME
Practice Address - Zip Code:04427-3031
Practice Address - Country:US
Practice Address - Phone:207-285-3281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS3410320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200550000Medicaid