Basic Information
| Provider Information | |||||||||
| NPI: | 1033367982 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERMED PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GANNETT DRIVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 FODEN RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 05/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | KENDALL | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2075233677 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 20D0088755 | ME | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.