1023321593 NPI number — MAINEHEALTH

Table of content: (NPI 1023321593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023321593 NPI number — MAINEHEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINEHEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MAINE MEDICAL PARTNERS LAKES REGION PRIMARY CARE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023321593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 BRAMHALL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04102-3134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-662-6562
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
584 ROOSEVELT TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDHAM
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-892-3233
Provider Business Practice Location Address Fax Number:
207-893-0752
Provider Enumeration Date:
07/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
INZANA
Authorized Official First Name:
LUGENE
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
SVP FINANCE/CFO
Authorized Official Telephone Number:
207-662-3538

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 37563 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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