=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578581377
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH A HIEMENGA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CAMPUS DR UNIT 121
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-396-7270
-----------------------------------------------------
Fax | 207-396-7944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 CAMPUS DR UNIT 121
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-396-7270
-----------------------------------------------------
Fax | 207-396-7944
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | JH046477
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number | 4301046477
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 4301046477
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number | MD26771
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------