1124084975 NPI number — MAINEGENERAL HEALTH ASSOCIATES

Table of content: (NPI 1124084975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124084975 NPI number — MAINEGENERAL HEALTH ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINEGENERAL HEALTH ASSOCIATES
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:
WINTHROP FAMILY PEDIATRICS AND ADOLESCENTS
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:
1124084975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 DRESDEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDINER
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04345-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-621-9337
Provider Business Mailing Address Fax Number:
207-621-3609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
WINTHROP
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04364-1486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-377-2114
Provider Business Practice Location Address Fax Number:
207-377-6112
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROWLEY
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT, MGHA
Authorized Official Telephone Number:
207-626-1063

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 164570011 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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