Provider Demographics
NPI:1205950003
Name:SMALL, LAURIE (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:102 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9692
Practice Address - Country:US
Practice Address - Phone:207-883-0069
Practice Address - Fax:207-883-0999
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15639207VX0201X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME261040099Medicaid
NH30202051Medicaid
MEMM9009Medicare PIN
ME261040099Medicaid
H46304Medicare UPIN
NH30202051Medicaid
MEMM900901Medicare PIN