Basic Information
Provider Information | |||||||||
NPI: | 1588990261 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITY OF PORTLAND MAINE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 389 CONGRESS ST | ||||||||
Address2: | ROOM 307 | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041013566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078748784 | ||||||||
FaxNumber: | 2078748913 | ||||||||
Practice Location | |||||||||
Address1: | 272 CONGRESS ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041013637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078742466 | ||||||||
FaxNumber: | 2078744625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/30/2009 | ||||||||
LastUpdateDate: | 10/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JENNINGS | ||||||||
AuthorizedOfficialFirstName: | JON | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CITY MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2078748689 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
ID | Type | State | Issuer | Description | 136041011 | 05 | ME |   | MEDICAID |