Provider Demographics
NPI:1831256478
Name:ERVIN, EDMUND D (MD)
Entity type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:D
Last Name:ERVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6117
Mailing Address - Country:US
Mailing Address - Phone:207-877-3470
Mailing Address - Fax:207-877-3471
Practice Address - Street 1:25 FIRST PARK DRIVE
Practice Address - Street 2:STE A
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963
Practice Address - Country:US
Practice Address - Phone:207-873-6183
Practice Address - Fax:207-873-4344
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME010650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107850099Medicaid
ME01513801Medicare PIN
ME084867Medicare ID - Type Unspecified
ME107850099Medicaid