1144342585 NPI number — PHYSICAL REHABILITATION OF SOUTHERN MAINE PC

Table of content: (NPI 1144342585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144342585 NPI number — PHYSICAL REHABILITATION OF SOUTHERN MAINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL REHABILITATION OF SOUTHERN MAINE PC
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:
MARY MACY MD
Provider Other Organization Name Type Code:
3
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:
1144342585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 810
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBROOK
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04098-0810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-854-1544
Provider Business Mailing Address Fax Number:
207-854-1516

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 BRIGHTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04102-2362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-497-2996
Provider Business Practice Location Address Fax Number:
207-497-3467
Provider Enumeration Date:
04/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MACY
Authorized Official First Name:
MARY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-854-1544

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  014605 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ME1098 . This is a "MEDICARE IND #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 1811907199 . This is a "INDIVIDUAL NPI #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: $$$$$$$$$ . This is a "SOCIAL SECURITY #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 061235 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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