Provider Demographics
NPI:1356328421
Name:MID-MAINE RADIOLOGY, P.A
Entity Type:Organization
Organization Name:MID-MAINE RADIOLOGY, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLENBECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-784-2554
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04903-0766
Mailing Address - Country:US
Mailing Address - Phone:207-873-0729
Mailing Address - Fax:207-873-4338
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-873-0729
Practice Address - Fax:207-873-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM3776Medicare PIN