Provider Demographics
NPI:1376599381
Name:EYECARE MEDICAL GROUP
Entity Type:Organization
Organization Name:EYECARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CMPE
Authorized Official - Phone:207-791-8234
Mailing Address - Street 1:53 SEWALL STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2625
Mailing Address - Country:US
Mailing Address - Phone:207-828-2020
Mailing Address - Fax:207-773-7034
Practice Address - Street 1:53 SEWALL STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2625
Practice Address - Country:US
Practice Address - Phone:207-828-2020
Practice Address - Fax:207-773-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36395261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME109280100Medicaid
ME109280100Medicaid