Healthcare Provider Details

I. General information

NPI: 1639194509
Provider Name (Legal Business Name): MAINEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 CONGRESS ST
PORTLAND ME
04101
US

IV. Provider business mailing address

300 SOUTHBOROUGH DR SUITE 201
SOUTH PORTLAND ME
04106-6914
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-2466
  • Fax: 207-774-4625
Mailing address:
  • Phone: 207-661-2000
  • Fax: 207-661-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LUGENE ANTHONY INZANA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 207-662-3538