Provider Demographics
NPI:1508342643
Name:MAINEHEALTH
Entity Type:Organization
Organization Name:MAINEHEALTH
Other - Org Name:ANGEL AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE CFO, MAINEHEALTH
Authorized Official - Prefix:
Authorized Official - First Name:LUGENE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:INZANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-662-3538
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-0111
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAINEHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-12
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1050341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102500000Medicaid
ME200009000025OtherANTHEM BLUE CROSS PROVIDER #