1699875674 NPI number — SOUTHERN MAINE PHYSICAL THERAPY

Table of content: (NPI 1699875674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699875674 NPI number — SOUTHERN MAINE PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MAINE PHYSICAL THERAPY
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:
1699875674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
449 COTTAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-4924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-799-9700
Provider Business Mailing Address Fax Number:
207-799-9706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
449 COTTAGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-4924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-799-9700
Provider Business Practice Location Address Fax Number:
207-799-9706
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AYRE
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-799-9700

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , 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: 2433023 . This is a "AETNA GROUP NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 040910 . This is a "ANTHEM GROUP NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 100482300 . This is a "DEPT OF LABOR WKERS COMP" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 130470100 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: DB3088 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: MNT112 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 5182235 . This is a "CIGNA HEALTH CARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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