Basic Information
Provider Information | |||||||||
NPI: | 1609356419 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAINEHEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FRANKLIN MEMORIAL HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 FRANKLIN HEALTH CMNS | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | ME | ||||||||
PostalCode: | 049386144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 111 FRANKLIN HEALTH CMNS | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | ME | ||||||||
PostalCode: | 049386144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077792356 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2018 | ||||||||
LastUpdateDate: | 05/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | INZANA | ||||||||
AuthorizedOfficialFirstName: | LUGENE | ||||||||
AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE CFO | ||||||||
AuthorizedOfficialTelephone: | 2076623538 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 36464 | ME | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 003078294 | 01 | CT | CONNECTICUT MEDICAID | OTHER | 101790000 | 05 | ME |   | MEDICAID | 99200037 | 01 | NH | NEW HAMPSHIRE MEDICAID | OTHER | 900209 | 01 | ME | HARVARD PILGRIM | OTHER | M17200 | 01 | ME | CIGNA | OTHER | 01633398 | 01 | NY | NEW YORK MEDICAID | OTHER | 1211234 | 01 | MA | MASSACHUSETTS MEDICAID | OTHER | 6320200 | 01 | ME | AETNA | OTHER | 000018 | 01 | ME | ANTHEM BLUE CROSS | OTHER |