MEDICARE: STARBOARD ANESTHESIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist

General Provider Information

NPI Number	:	1518734755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STARBOARD ANESTHESIA LLC

Provider Business Mailing Address
First Line	:	1072 SHORE RD
Second Line	:
City	:	CAPE ELIZABETH
State	:	ME
Zip	:	04107-1920
Country	:	US
Telephone Number	:	617-710-7433
Fax Number	:

Provider Business Practice Location Address
First Line	:	1072 SHORE RD
Second Line	:
City	:	CAPE ELIZABETH
State	:	ME
Zip	:	04107-1920
Country	:	US
Telephone Number	:	617-710-7433
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JULIE A OUELLETTE
Credential	:	CRNA
Telephone Number	:	617-710-7433

Provider Enumeration Date	:	12/07/2023
Last Update Date	:	12/07/2023

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