1912094806 NPI number — MAINEHEALTH

Table of content: (NPI 1912094806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912094806 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:
ST. ANDREWS HOSPITAL
Provider Other Organization Name Type Code:
4
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:
1912094806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOOTHBAY HARBOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04538-0417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-633-2121
Provider Business Mailing Address Fax Number:
207-633-5389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 MILES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAMARISCOTTA
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04543-4047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-563-1234
Provider Business Practice Location Address Fax Number:
207-633-5389
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
INZANA
Authorized Official First Name:
LUGENE
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSOCIATE CFO, MAINEHEALTH
Authorized Official Telephone Number:
207-661-5452

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  38124 , 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: 1912094806-001 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101560000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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