Basic Information
| Provider Information | |||||||||
| NPI: | 1881719763 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF PORTLAND MAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 389 CONGRESS ST | ||||||||
| Address2: | ROOM 307 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041013529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078748784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 INDIA ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041014211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078748446 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | JENNINGS | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CITY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2078748689 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0905X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local |
ID Information
| ID | Type | State | Issuer | Description | 136040600 | 05 | ME | MEDICAID |