Basic Information
Provider Information | |||||||||
NPI: | 1811288061 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAINEHEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WESTERN MAINE PEDIATRICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 181 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | NORWAY | ||||||||
State: | ME | ||||||||
PostalCode: | 042685664 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077435933 | ||||||||
FaxNumber: | 2077431566 | ||||||||
Practice Location | |||||||||
Address1: | 193 MAIN ST | ||||||||
Address2: | SUITE 9 | ||||||||
City: | NORWAY | ||||||||
State: | ME | ||||||||
PostalCode: | 042685645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077438766 | ||||||||
FaxNumber: | 2077431579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2011 | ||||||||
LastUpdateDate: | 05/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | INZANA | ||||||||
AuthorizedOfficialFirstName: | LUGENE | ||||||||
AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE CFO, MAINEHEALTH | ||||||||
AuthorizedOfficialTelephone: | 2076623538 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MAINEHEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 37353 | ME | N |   | Hospitals | General Acute Care Hospital | Critical Access | 363LP0200X | 37353 | ME | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 208000000X | 37353 | ME | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.