Basic Information
| Provider Information | |||||||||
| NPI: | 1861720906 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITY OF PORTLAND MAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 389 CONGRESS ST | ||||||||
| Address2: | ROOM 307 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041013566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078748784 | ||||||||
| FaxNumber: | 2078748913 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 PORTLAND ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041012912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078748445 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2009 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | REES | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CITY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2078748944 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KI0005X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | Clinical & Laboratory Immunology |
ID Information
| ID | Type | State | Issuer | Description | 136041100 | 05 | ME | MEDICAID |