Basic Information
| Provider Information | |||||||||
| NPI: | 1083949184 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINEGENERAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAINEGENERAL SPECIALITY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O BOX 860 | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078724454 | ||||||||
| FaxNumber: | 2078724467 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MEDICAL CENTER PARKWAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078724454 | ||||||||
| FaxNumber: | 2078724467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2009 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | BRANN | ||||||||
| AuthorizedOfficialFirstName: | TERRANCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2076261230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAINEGENERAL HEALTH | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208800000X | 37283 | ME | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207X00000X | 37283 | ME | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 282N00000X | 37283 | ME | Y | Hospitals | General Acute Care Hospital |
No ID Information.