Basic Information
| Provider Information | |||||||||
| NPI: | 1982243747 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALOVICH | ||||||||
| FirstName: | JESSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD STE 300 | ||||||||
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| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735035 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 STATE ST STE 121 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079734266 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2019 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2052 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.