Provider Demographics
NPI:1477692010
Name:FAMILY HEALTH CENTER OF SOUTHERN MAINE, P.A.
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER OF SOUTHERN MAINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KAZILIONIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-775-7758
Mailing Address - Street 1:778 MAIN ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5447
Mailing Address - Country:US
Mailing Address - Phone:207-775-7758
Mailing Address - Fax:207-879-7758
Practice Address - Street 1:778 MAIN ST
Practice Address - Street 2:SUITE #1
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5447
Practice Address - Country:US
Practice Address - Phone:207-775-7758
Practice Address - Fax:207-879-7758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME041126OtherBLUE CROSS
ME2541034OtherAETNA
MEM197320OtherCIGNA
MEM197320OtherCIGNA
ME071170Medicare ID - Type UnspecifiedMEDICARE
MED94297Medicare UPIN