Basic Information
| Provider Information | |||||||||
| NPI: | 1346267879 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINEHEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MMC FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 WALLACE AVE | ||||||||
| Address2: | MAINE MEDICAL PARTNERS | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077610650 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 272 CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077610650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | INZANA | ||||||||
| AuthorizedOfficialFirstName: | LUGENE | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE CFO | ||||||||
| AuthorizedOfficialTelephone: | 2076623538 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 36236 | ME | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 102500000 | 05 | ME | MEDICAID | 200009000025 | 01 | ME | ANTHEM BLUE CROSS PROV # | OTHER |