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General NPI Number Information
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NPI Number | 1790871994
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Entity Type | Organization
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Legal Business Name | WATERVILLE PEDIATRICS PA
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 04/02/2021
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Provider Practice Location Address
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Address Line | 295C KENNEDY MEMORIAL DR
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City | WATERVILLE
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State | ME
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Zip | 04901-4535
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Country | US
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Telephone | 207-873-5437
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Fax | 207-872-6037
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Provider Business Mailing Address
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Address Line | 295C KENNEDY MEMORIAL DR
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City | WATERVILLE
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State | ME
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Zip | 04901-4535
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Country | US
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Telephone | 207-873-5437
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Fax | 207-872-6037
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Authorized Official
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Title or Position | TREASURER
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Name | JEFFREY STONE
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Credential | D.O.
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Telephone | 207-873-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 1317
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License Number State | ME
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