Healthcare Provider Details

I. General information

NPI: 1780788372
Provider Name (Legal Business Name): MAINEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WEST ST
PORTLAND ME
04102
US

IV. Provider business mailing address

301 US ROUTE 1 BUILDING C
SCARBOROUGH ME
04074-7609
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-7180
  • Fax: 207-662-7190
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: LUGENE ANTHONY INZANA
Title or Position: SVP FINANCE/CFO
Credential:
Phone: 207-662-3538