=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134185648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF PORTLAND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2006
-----------------------------------------------------
Last Update Date | 04/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 380 CONGRESS ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-874-8400
-----------------------------------------------------
Fax | 207-874-8410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16020
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04243-9597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-874-8400
-----------------------------------------------------
Fax | 207-874-8410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT FIRE CHIEF
-----------------------------------------------------
Name | CHRISTOPHER H GOODALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-874-8409
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 546
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 0546
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------