Basic Information
Provider Information | |||||||||
NPI: | 1659475036 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAINEHEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KENNETH AULT MD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 39 WALLACE AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041066143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077610650 | ||||||||
FaxNumber: | 2077618198 | ||||||||
Practice Location | |||||||||
Address1: | 81 RESEARCH DR | ||||||||
Address2: |   | ||||||||
City: | SCARBOROUGH | ||||||||
State: | ME | ||||||||
PostalCode: | 04074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078858130 | ||||||||
FaxNumber: | 2078858110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2006 | ||||||||
LastUpdateDate: | 05/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | INZANA | ||||||||
AuthorizedOfficialFirstName: | LUGENE | ||||||||
AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2076623538 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RH0000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
ID | Type | State | Issuer | Description | 119910015 | 05 | ME |   | MEDICAID |