Basic Information
| Provider Information | |||||||||
| NPI: | 1912233826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERRIMACK RIVER MEDICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LAKEPOINTE DR | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143793300 | ||||||||
| FaxNumber: | 2148539018 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041021908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072212292 | ||||||||
| FaxNumber: | 2072212297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2009 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2143793300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 151640000 | 05 | ME | MEDICAID |