NPIMap

Individual provider Active NPI

Bethany T Lake, MD

  • Family Medicine Physician
  • E Waterboro, ME
National Provider Identifier
1649234378
Registry record updated Dec 18, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
015660 Issued in ME
Practice address
10 Goodall Drive
Suite 100
E. Waterboro, ME 04030
Phone
(207) 490-7970
Fax
(207) 282-9128
NPI assigned
Apr 12, 2006
Last updated
Dec 18, 2014By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 18, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 015660 ME Primary

Addresses

Primary practice location

10 Goodall Drive
Suite 100
E. Waterboro, ME 04030

Mailing address

1 Medical Center Drive
PO Box 626
Biddeford, ME 04005
Phone (207) 282-9080

Other identifiers 1

IdentifierTypeStateIssuer
247150099MedicaidME

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20050617000597 ME Practitioner - Family Practice 7618911868 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Vermont College of Medicine, 1998
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
MainehealthGroup PAC ID 7517860588, 2,616 clinicians

Practice addresses (Care Compare)

13 Industrial Park Rd
Saco, ME 04072-1804
Phone (207) 283-8800

22 Bramhall St
Portland, ME 04102-3134
Phone (207) 885-9905

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
015660MEMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Mainehealth CurrentSince Nov 1, 2018 Accepting new patients
Mainehealth CurrentSince Jan 5, 2015 Accepting new patients
Mainehealth CurrentSince Jan 5, 2015 Accepting new patients
Mainehealth Current Accepting new patients
Mainehealth CurrentSince Nov 1, 2018 Accepting new patients
Mercy Hospital Past Accepting new patients
Mainehealth Family Medicine Past Accepting new patients
Mercy Hospital Past Accepting new patients

Locations

1 Medical Dr
Biddeford, ME 04005
Phone (207) 283-7000

10 Goodall Dr
Ste 100
East Waterboro, ME 04030
Phone (207) 490-7970

22 Bramhall St
Portland, ME 04102
Phone (207) 662-2179

Interoperability endpoints

  • Direct secure messaging: blake156958@direct.mmc.mainehealth.org

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 39

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 39

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1144800000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1418860800000",
    "number": "1649234378",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 MEDICAL CENTER DRIVE",
            "address_2": "PO BOX 626",
            "city": "BIDDEFORD",
            "state": "ME",
            "postal_code": "04005",
            "telephone_number": "207-282-9080",
            "fax_number": "207-282-9180"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10 GOODALL DRIVE",
            "address_2": "SUITE 100",
            "city": "E. WATERBORO",
            "state": "ME",
            "postal_code": "04030",
            "telephone_number": "207-490-7970",
            "fax_number": "207-282-9128"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LAKE",
        "first_name": "BETHANY",
        "middle_name": "T",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-04-12",
        "last_updated": "2014-12-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ME",
            "license": "015660",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "247150099",
            "state": "ME"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in E Waterboro, ME

Sources for this page

Verify at the official NPI Registry.