1487896080 NPI number — CITY OF PORTLAND MAINE

Table of content: (NPI 1487896080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487896080 NPI number — CITY OF PORTLAND MAINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF PORTLAND MAINE
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:
Provider Other Organization Name Type Code:
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:
1487896080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
389 CONGRESS ST
Provider Second Line Business Mailing Address:
ROOM 307
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04101-3566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-874-8784
Provider Business Mailing Address Fax Number:
207-874-8913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 BRACKETT ST
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:
04102-3825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-874-8786
Provider Business Practice Location Address Fax Number:
208-874-8447
Provider Enumeration Date:
03/27/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JENNINGS
Authorized Official First Name:
JON
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CITY MANAGER
Authorized Official Telephone Number:
207-874-8689

Provider Taxonomy Codes

  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136040603 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".