Basic Information
| Provider Information | |||||||||
| NPI: | 1902130743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITY OF PORTLAND MAINE, HHS PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 389 CONGRESS ST | ||||||||
| Address2: | ROOM 307 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041013566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078748784 | ||||||||
| FaxNumber: | 2978748913 | ||||||||
| Practice Location | |||||||||
| Address1: | 389 CONGRESS ST | ||||||||
| Address2: | ROOM 307 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041013566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078748784 | ||||||||
| FaxNumber: | 2978748913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2009 | ||||||||
| LastUpdateDate: | 09/28/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | E, | ||||||||
| AuthorizedOfficialTitleorPosition: | CITY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2078748689 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CITY OF PORTLAND MAINE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | Y | Agencies | Public Health or Welfare |
No ID Information.