Healthcare Provider Details

I. General information

NPI: 1205924594
Provider Name (Legal Business Name): CASCO MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 OCEAN AVE SUITE 2 - SECOND FLOOR
PORTLAND ME
04103
US

IV. Provider business mailing address

535 OCEAN AVE SUITE 2 - SECOND FLOOR
PORTLAND ME
04103
US

V. Phone/Fax

Practice location:
  • Phone: 207-518-6000
  • Fax: 207-518-6001
Mailing address:
  • Phone: 207-518-6000
  • Fax: 207-518-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAM082082
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC5507
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD12923
License Number StateME

VIII. Authorized Official

Name: MR. CHARLES T RAINVILLE III
Title or Position: PRESIDENT
Credential:
Phone: 207-518-6041