Basic Information
| Provider Information | |||||||||
| NPI: | 1659575371 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAINE COAST ANESTHESIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9132 | ||||||||
| Address2: | |||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 329 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040113310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073732250 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EWERT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2073732250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | ME | MEDICAID |