Healthcare Provider Details

I. General information

NPI: 1134516701
Provider Name (Legal Business Name): ANNE LONGTINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 WATERVILLE ST
PORTLAND ME
04101
US

IV. Provider business mailing address

300 MAIN ST
LEWISTON ME
04240-7027
US

V. Phone/Fax

Practice location:
  • Phone: 314-255-9796
  • Fax:
Mailing address:
  • Phone: 207-795-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD22067
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: