Healthcare Provider Details

I. General information

NPI: 1497052518
Provider Name (Legal Business Name): MAINEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 SPRING ST 2ND FLOOR
SCARBOROUGH ME
04074
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 207-883-1414
  • Fax: 207-883-1010
Mailing address:
  • Phone: 207-662-6562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number37563
License Number StateME
# 7
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: LUGENE ANTHONY INZANA
Title or Position: ASSCOAITE CFO
Credential:
Phone: 207-662-3538