=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720044878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAINE EYE CENTER, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2006
-----------------------------------------------------
Last Update Date | 10/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 LOWELL ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-774-8277
-----------------------------------------------------
Fax | 207-523-5310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 LOWELL ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-774-8277
-----------------------------------------------------
Fax | 207-523-5310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF REVENUE CYCLE
-----------------------------------------------------
Name | JUDITH MCCANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 848-219-2109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 156FC0800X
-----------------------------------------------------
Taxonomy Name | Contact Lens Technician/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 156FX1101X
-----------------------------------------------------
Taxonomy Name | Ophthalmic Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 156FX1202X
-----------------------------------------------------
Taxonomy Name | Optometric Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------