1417952318 NPI number — PORTLAND FOOT & ANKLE, PA

Table of content: (NPI 1417952318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417952318 NPI number — PORTLAND FOOT & ANKLE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTLAND FOOT & ANKLE, PA
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:
1417952318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 MARGINAL WAY
Provider Second Line Business Mailing Address:
4TH FLOOR
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-879-1339
Provider Business Mailing Address Fax Number:
207-879-1092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
68 MARGINAL WAY
Provider Second Line Business Practice Location Address:
4TH FLOOR
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-879-1339
Provider Business Practice Location Address Fax Number:
207-879-1092
Provider Enumeration Date:
06/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JURIS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
207-879-1339

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 480030888 . This is a "K. PAUL FLANIGAN" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: CH4448 . This is a "PALMETTO GROUP" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 0619920001 . This is a "DMERC GROUP" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 480023694 . This is a "ROBERT S. JURIS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: CH4448 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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