=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629159298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONATHAN HERLAND D SC MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 163 VAN BUREN RD
-----------------------------------------------------
City | CARIBOU
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04736-3567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-927-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 198 HIGH ST
-----------------------------------------------------
City | CARIBOU
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04736-1836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-927-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JONATHAN S HERLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-927-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 015192
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------