MEDICARE: STATE OF MAINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	283Q00000X	Psychiatric Hospital

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	204008	OTHER	ME	MEDICARE ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	003287	OTHER	ME	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053319566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF MAINE

Provider Business Mailing Address
First Line	:	109 CAPITOL STREET SHS #11 REIMBURSEMENT UNIT
Second Line	:
City	:	AUGUSTA
State	:	ME
Zip	:	04333-0011
Country	:	US
Telephone Number	:	207-287-2293
Fax Number	:	207-287-1862

Provider Business Practice Location Address
First Line	:	250 ARSENAL ST
Second Line	:
City	:	AUGUSTA
State	:	ME
Zip	:	04333-0011
Country	:	US
Telephone Number	:	207-287-2293
Fax Number	:	207-287-1862

Authorized Official
Title or Position	:	FINANCIAL MANAGER
Name	:	MS. JENNIFER GAGNON
Credential	:
Telephone Number	:	207-624-4675

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	06/14/2019

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1821079252 — MS. DORIS D SOLMITZ NP
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1992782718 — MR. JAMES L SPROUSE PA-C
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1841380235 — RUSSELL B KIMBALL PA-C
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Directions to “STATE OF MAINE ” Practice Location

Language	Start Address	Practice Location

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