Provider Demographics
NPI:1184020091
Name:STATE OF MAINE
Entity Type:Organization
Organization Name:STATE OF MAINE
Other - Org Name:DOROTHEA DIX PSYCHIATRIC CENTER OUT PATIENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:WEBB
Authorized Official - Last Name:CODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-941-4192
Mailing Address - Street 1:109 CAPITOL STREET SHS #11, REIMBURSEMENT UNIT
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04333-0011
Mailing Address - Country:US
Mailing Address - Phone:207-287-7418
Mailing Address - Fax:
Practice Address - Street 1:656 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5609
Practice Address - Country:US
Practice Address - Phone:207-287-7418
Practice Address - Fax:207-287-1862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME681294251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME204004Medicare UPIN