Provider Demographics
NPI:1265445464
Name:CENTRAL MAINE ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:CENTRAL MAINE ORTHOTICS & PROSTHETICS
Other - Org Name:PENOBSCOT ORTHOTICS & PROSTHETICS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/ORTHOTIST
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:207-873-1131
Mailing Address - Street 1:36 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6514
Mailing Address - Country:US
Mailing Address - Phone:207-873-1131
Mailing Address - Fax:207-872-6014
Practice Address - Street 1:36 SILVER ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6514
Practice Address - Country:US
Practice Address - Phone:207-873-1131
Practice Address - Fax:207-872-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME128630000Medicaid
ME154570000Medicaid
MEM23300OtherCIGNA BILLING NUMBER
ME015509OtherBLUE CROSS BILLING NUMBER
MEM23300OtherCIGNA BILLING NUMBER
ME1350400001Medicare ID - Type UnspecifiedPROVIDER NUMBER