Healthcare Provider Details

I. General information

NPI: 1871706465
Provider Name (Legal Business Name): MSAD #17
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 MAIN ST
OXFORD ME
04270-3390
US

IV. Provider business mailing address

1570 MAIN ST
OXFORD ME
04270-3390
US

V. Phone/Fax

Practice location:
  • Phone: 207-743-8972
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number251B00000X
License Number StateME

VIII. Authorized Official

Name: DR. MARK EASTMAN
Title or Position: SUPERINTENDENT
Credential:
Phone: 207-743-8972