Basic Information
| Provider Information | |||||||||
| NPI: | 1558305847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINEHEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FCHN NETWORK | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 111 FRANKLIN HEALTH COMMONS | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049386144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077792048 | ||||||||
| FaxNumber: | 2077792784 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 FRANKLIN HEALTH CMNS | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049386144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077792356 | ||||||||
| FaxNumber: | 2077792240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | INZANA | ||||||||
| AuthorizedOfficialFirstName: | LUGENE | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP FINANCE, CFO | ||||||||
| AuthorizedOfficialTelephone: | 2076623538 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAINEHEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 36464 | ME | N | Hospitals | General Acute Care Hospital | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 003078294 | 01 | CT | CONNECTICUT MEDICAID | OTHER | 1211234 | 01 | MA | MASSACHUSETTS MEDICAID | OTHER | 900209 | 01 | ME | HARVARD PILGRIM | OTHER | 000018 | 01 | ME | ANTHEM BLUE CROSS | OTHER | 99200037 | 01 | NH | NEW HAMPSHIRE MEDICAID | OTHER | M17200 | 01 | ME | CIGNA | OTHER | 01633398 | 01 | NY | NEW YORK MEDICAID | OTHER | 101790000 | 05 | ME | MEDICAID | 6320200 | 01 | ME | AETNA | OTHER |