=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801077128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RETINA CENTER OF MAINE, LLC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 04/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 FORE RIVER PKWY STE 480
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-773-3937
-----------------------------------------------------
Fax | 207-773-0801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 195 FORE RIVER PKWY STE 480
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04102-2787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-773-3937
-----------------------------------------------------
Fax | 207-773-0801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD / PRACTICE OWNER
-----------------------------------------------------
Name | DR. MARK WILSON BALLES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 207-773-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | MD14047
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------