Provider Demographics
NPI:1003113127
Name:MAINEHEALTH
Entity Type:Organization
Organization Name:MAINEHEALTH
Other - Org Name:MMP ORTHOPEDICS ( DIV OF ORTHOPEDIC TRAUMA & FRACTURE CARE)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE CFO
Authorized Official - Prefix:
Authorized Official - First Name:LUGENE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:INZANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-662-3538
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-6562
Mailing Address - Fax:
Practice Address - Street 1:335 BRIGHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2363
Practice Address - Country:US
Practice Address - Phone:207-662-8600
Practice Address - Fax:207-662-8668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAINEHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-25
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207XX0801X, 363AS0400X
ME37563282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200009Medicare Oscar/Certification