=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912133943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELL WOMAN CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2009
-----------------------------------------------------
Last Update Date | 11/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 174 S FREEPORT RD SUITE 1A
-----------------------------------------------------
City | FREEPORT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04032-6145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-865-7088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 S FREEPORT RD STE. 1A
-----------------------------------------------------
City | FREEPORT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04032-6145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-497-2996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING REPRESENTATIVE
-----------------------------------------------------
Name | SUSAN M CORBETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-497-2996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 012979
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------