Basic Information
| Provider Information | |||||||||
| NPI: | 1023321593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINEHEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAINE MEDICAL PARTNERS LAKES REGION PRIMARY CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 BRAMHALL ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076626562 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 584 ROOSEVELT TRL | ||||||||
| Address2: | |||||||||
| City: | WINDHAM | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078923233 | ||||||||
| FaxNumber: | 2078930752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | INZANA | ||||||||
| AuthorizedOfficialFirstName: | LUGENE | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2076623538 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAINEHEALTH | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 282N00000X | 37563 | ME | N | Hospitals | General Acute Care Hospital | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.