Provider Demographics
NPI:1538236534
Name:ST. MARY'S ANESTHESIA ASSOCIATES, P.A.
Entity type:Organization
Organization Name:ST. MARY'S ANESTHESIA ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:P
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:207-755-3715
Mailing Address - Street 1:PO BOX 1823
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1823
Mailing Address - Country:US
Mailing Address - Phone:207-755-3715
Mailing Address - Fax:207-755-3728
Practice Address - Street 1:93 CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6030
Practice Address - Country:US
Practice Address - Phone:207-755-3715
Practice Address - Fax:207-755-3728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME125530100Medicaid
500092Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER