Healthcare Provider Details

I. General information

NPI: 1316995624
Provider Name (Legal Business Name): MAINE MOLECULAR IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 12/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS DR
SCARBOROUGH ME
04074-9692
US

IV. Provider business mailing address

PO BOX 414025
BOSTON MA
02241-4025
US

V. Phone/Fax

Practice location:
  • Phone: 800-734-4132
  • Fax: 800-273-2377
Mailing address:
  • Phone: 949-282-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: BRIAN G DRAZBA
Title or Position: SENIOR V.P. & CHIEF ACCOUNTING OFCR
Credential:
Phone: 949-282-6000