Basic Information
| Provider Information | |||||||||
| NPI: | 1184161085 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAINE MOLECULAR IMAGING, LLC | ||||||||
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| OtherOrganizationName: | MAINE MOLECULAR IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5775 WAYZATA BLVD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525256338 | ||||||||
| FaxNumber: | 9529055697 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 GLEN COVE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 048564240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078831285 | ||||||||
| FaxNumber: | 2078833813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2017 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | AHERN | ||||||||
| AuthorizedOfficialFirstName: | RAMONA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SPECIAL ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9527384441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.