Basic Information
| Provider Information | |||||||||
| NPI: | 1467422733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERMED PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GANNETT DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 GANNETT DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041065900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | FERENTZ | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2075233648 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.