=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750836656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN MAINE HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2016
-----------------------------------------------------
Last Update Date | 08/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25A JUNE ST
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04073-2642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-283-7000
-----------------------------------------------------
Fax | 207-283-7063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MEDICAL CENTER DR
-----------------------------------------------------
City | BIDDEFORD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04005-9422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-283-7000
-----------------------------------------------------
Fax | 207-283-7063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR VP/CFO
-----------------------------------------------------
Name | NORMAN D BELAIR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-283-7898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 38427
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------