1699776146 NPI number — STATE OF MAINE

Table of content: (NPI 1699776146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699776146 NPI number — STATE OF MAINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF 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:
6
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:
1699776146
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 CAPITOL STREET
Provider Second Line Business Mailing Address:
STATE HOUSE STATION #11, REIMBURSEMENT UNIT
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04330-6846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-287-7418
Provider Business Mailing Address Fax Number:
207-287-1862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
656 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-5609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-941-4192
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CODY
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
WEBB
Authorized Official Title or Position:
FINANCIAL MANAGER
Authorized Official Telephone Number:
207-941-4192

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 135910900 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003288 . This is a "BLUE CROSS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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