=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841672094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAINE THORACIC SURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2015
-----------------------------------------------------
Last Update Date | 06/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 NORTHBROOK DR # B
-----------------------------------------------------
City | FALMOUTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04105-1379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-781-8594
-----------------------------------------------------
Fax | 207-781-3493
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 NORTHBROOK DR # B
-----------------------------------------------------
City | FALMOUTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04105-1379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-781-8594
-----------------------------------------------------
Fax | 207-781-3493
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SETH D BLANK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 207-781-8594
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | MD13305
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------