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General NPI Number Information
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NPI Number | 1629154463
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Entity Type | Organization
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Legal Business Name | EVERGREEN GYNECOLOGY ASSOCIATES, P.A.
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Dates
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Enumeration Date | 10/27/2006
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Last Update Date | 10/16/2013
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Provider Practice Location Address
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Address Line | 700 MOUNT HOPE AVE SUITE 430
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City | BANGOR
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State | ME
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Zip | 04401-5691
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Country | US
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Telephone | 207-947-8658
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Fax | 207-947-4440
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Provider Business Mailing Address
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Address Line | 700 MOUNT HOPE AVE SUITE 430
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City | BANGOR
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State | ME
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Zip | 04401-5691
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Country | US
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Telephone | 207-947-8658
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JANE N. LAEGER
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Credential | M.D.
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Telephone | 207-947-8658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 011478
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License Number State | ME
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