Healthcare Provider Details

I. General information

NPI: 1023321593
Provider Name (Legal Business Name): MAINEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

584 ROOSEVELT TRL
WINDHAM ME
04062
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 207-892-3233
  • Fax: 207-893-0752
Mailing address:
  • Phone: 207-662-6562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number37563
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LUGENE ANTHONY INZANA
Title or Position: SVP FINANCE/CFO
Credential:
Phone: 207-662-3538