Basic Information
Provider Information | |||||||||
NPI: | 1710215751 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAINE MEDICAL PARTNERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAINE MEDICAL PARTNERS UROLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 SOUTHBOROUGH DR | ||||||||
Address2: | SUITE 201 | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041066914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2076612000 | ||||||||
FaxNumber: | 2076612033 | ||||||||
Practice Location | |||||||||
Address1: | 100 BRICKHILL AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041061999 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077731728 | ||||||||
FaxNumber: | 2077724062 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2009 | ||||||||
LastUpdateDate: | 05/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KASABIAN | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2076612000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088P0231X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 363AM0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LF0000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208800000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 30217105 | 05 | NH |   | MEDICAID | 119910029 | 05 | ME |   | MEDICAID |