Basic Information
| Provider Information | |||||||||
| NPI: | 1629558432 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAINEHEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | LINCOLN MEDICAL PARTNERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | BOOTHBAY HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045380417 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 35 MILES ST | ||||||||
| Address2: | |||||||||
| City: | DAMARISCOTTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 045434047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075631234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | INZANA | ||||||||
| AuthorizedOfficialFirstName: | LUGENE | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE CFO | ||||||||
| AuthorizedOfficialTelephone: | 2076623538 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 38124 | ME | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 101560000 | 05 | ME | MEDICAID | 1912094806-001 | 05 | ME | MEDICAID |