Basic Information
| Provider Information | |||||||||
| NPI: | 1174897078 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINE MEDICAL PARTNERS | ||||||||
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| OtherOrganizationName: | MAINE MEDICAL PARTNERS CARDIOVASCULAR SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 RIVERSIDE STREET | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612095 | ||||||||
| FaxNumber: | 2076612033 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077738161 | ||||||||
| FaxNumber: | 2077731489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2012 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | JAUREGUI | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT & CVO | ||||||||
| AuthorizedOfficialTelephone: | 2076615414 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363LA2100X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 208G00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.