Provider Demographics
NPI:1962731471
Name:GARY, RICHARD ALLAN
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALLAN
Last Name:GARY
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 217
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0217
Mailing Address - Country:US
Mailing Address - Phone:207-944-1848
Mailing Address - Fax:
Practice Address - Street 1:363 FERN ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4060
Practice Address - Country:US
Practice Address - Phone:207-944-1848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432708200OtherSTATE OF MAINE PROVIDER NUMBER