Provider Demographics
NPI:1376781153
Name:STATE OF MAINE
Entity Type:Organization
Organization Name:STATE OF MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALDACCI
Authorized Official - Suffix:
Authorized Official - Credentials:GOV
Authorized Official - Phone:207-287-3531
Mailing Address - Street 1:91 CAMDEN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-2455
Mailing Address - Country:US
Mailing Address - Phone:207-596-4200
Mailing Address - Fax:207-596-4370
Practice Address - Street 1:91 CAMDEN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2455
Practice Address - Country:US
Practice Address - Phone:207-596-4200
Practice Address - Fax:207-596-4370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-01
Last Update Date:2009-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME8666065305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEXVH0920M50019OtherBLUE CROSS BLUE SHIELD OF MAINE