=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245516723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN TAYLOR QUIGLEY PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2011
-----------------------------------------------------
Last Update Date | 10/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 HIGH ST
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04240-7616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-795-8260
-----------------------------------------------------
Fax | 207-795-8280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 HIGH ST
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04240-7616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-795-8260
-----------------------------------------------------
Fax | 207-795-8280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA001303
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------