Basic Information
| Provider Information | |||||||||
| NPI: | 1609949908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAINE HEART SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 818 CONGRESS ST | ||||||||
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| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077738161 | ||||||||
| FaxNumber: | 2077731489 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077738161 | ||||||||
| FaxNumber: | 2077731489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 04/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | BUCHANAN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2077738161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 105260000 | 05 | ME | MEDICAID |