Healthcare Provider Details

I. General information

NPI: 1275503922
Provider Name (Legal Business Name): KEASHA DANIELLE MARESCOT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEASHA DANIELLE GRINDLEY MD

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 SOKOKIS TRAIL
E WATERBORO ME
04030
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 207-247-6742
  • Fax: 207-247-6114
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number015675
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier046260
Identifier TypeOTHER
Identifier State
Identifier IssuerANTHEM
# 2
IdentifierM555815
Identifier TypeOTHER
Identifier StateNH
Identifier IssuerCIGNA
# 3
Identifier3179929
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 4
Identifier0055B749
Identifier TypeOTHER
Identifier State
Identifier IssuerCHAMPUS
# 5
Identifier30205519
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer
# 6
Identifier046261
Identifier TypeOTHER
Identifier StateME
Identifier IssuerBLUE SHIELD
# 7
Identifier050562391
Identifier TypeOTHER
Identifier State
Identifier IssuerCOMMERCIAL
# 8
Identifier281130099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: