Healthcare Provider Details

I. General information

NPI: 1558456459
Provider Name (Legal Business Name): PORTLAND ENDOSCOPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 MARGINAL WAY
PORTLAND ME
04101-2438
US

IV. Provider business mailing address

161 MARGINAL WAY
PORTLAND ME
04101-2438
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-7964
  • Fax: 207-773-9073
Mailing address:
  • Phone: 207-773-7964
  • Fax: 207-773-9073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA GOUSSE
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 207-773-7964