Provider Demographics
NPI:1558456459
Name:PORTLAND ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:PORTLAND ENDOSCOPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUSSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-773-7964
Mailing Address - Street 1:161 MARGINAL WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2438
Mailing Address - Country:US
Mailing Address - Phone:207-773-7964
Mailing Address - Fax:207-773-9073
Practice Address - Street 1:161 MARGINAL WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2438
Practice Address - Country:US
Practice Address - Phone:207-773-7964
Practice Address - Fax:207-773-9073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME118790000Medicaid
NH30621368Medicaid
ME201003Medicare ID - Type UnspecifiedGROUP NUMBER