Basic Information
| Provider Information | |||||||||
| NPI: | 1285738310 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAINE MEDICAL PARTNERS | ||||||||
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| OtherOrganizationName: | MAINE MEDICAL PARTNERS GENERAL SURGERY, TRAUMA & CRITICAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SOUTHBOROUGH DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612000 | ||||||||
| FaxNumber: | 2076612033 | ||||||||
| Practice Location | |||||||||
| Address1: | 887 CONGRESS ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077742544 | ||||||||
| FaxNumber: | 2077740459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | KASABIAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2076612000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | ME | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 363LA2200X | ME | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | ME | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LC0200X | ME | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 208600000X | ME | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 119910017 | 05 | ME | MEDICAID | 30002633 | 05 | NH | MEDICAID |