Basic Information
| Provider Information | |||||||||
| NPI: | 1811906589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LAWRENCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1599 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044021599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079455247 | ||||||||
| FaxNumber: | 2079470435 | ||||||||
| Practice Location | |||||||||
| Address1: | 735 WILSON ST | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079922601 | ||||||||
| FaxNumber: | 2079892280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD12226 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1044064 | 01 | ME | AETNA | OTHER | 010474554 | 01 | ME | MEDNET | OTHER | D78793 | 01 | ME | HARVARD PLIGRIM HEALTHCAR | OTHER | M61771 | 01 | ME | CIGNA HEALTHCARE | OTHER | 017716 | 01 | ME | ANTHEM BC BS | OTHER | 319680099 | 05 | ME | MEDICAID |