=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295607836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERMED, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2025
-----------------------------------------------------
Last Update Date | 09/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 FODEN, WEST
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-523-3767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 GANNETT DR STE C
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-347-2947
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | ROGER POITRAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-347-2947
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------