Basic Information
| Provider Information | |||||||||
| NPI: | 1376611996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINERNEY | ||||||||
| FirstName: | PAIGE | ||||||||
| MiddleName: | N.C. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CREIGHTON | ||||||||
| OtherFirstName: | PAIGE | ||||||||
| OtherMiddleName: | N. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 66 STONE ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076263455 | ||||||||
| FaxNumber: | 2076211107 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 STONE ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043305227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076263455 | ||||||||
| FaxNumber: | 2076211107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 2003 | ME | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 432808799 | 05 | ME | MEDICAID |