Provider Demographics
NPI:1225232606
Name:MAINEHEALTH
Entity Type:Organization
Organization Name:MAINEHEALTH
Other - Org Name:MMC FAMILY PRACTICE RESIDENCY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP FINANCE/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 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:272 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-874-2466
Practice Address - Fax:207-774-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30216370Medicaid
NH30216370Medicaid
ME500065Medicare PIN