Provider Demographics
NPI:1588866966
Name:MID MAINE GASTROENTEROLOGY
Entity type:Organization
Organization Name:MID MAINE GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-872-2424
Mailing Address - Street 1:325E KENNEDY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4531
Mailing Address - Country:US
Mailing Address - Phone:207-872-2424
Mailing Address - Fax:207-872-2099
Practice Address - Street 1:325E KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4531
Practice Address - Country:US
Practice Address - Phone:207-872-2424
Practice Address - Fax:207-872-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEG0078OtherANTHEM
MEMM3343Medicare PIN