=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487686242
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OSWALDO BISBAL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2006
-----------------------------------------------------
Last Update Date | 09/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 BATES ST STE 202
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04240-7637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-784-5784
-----------------------------------------------------
Fax | 207-784-1477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 BATES ST STE 202
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04240-7637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-784-5784
-----------------------------------------------------
Fax | 207-784-1477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 0101238351
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 017819
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------