Provider Demographics
NPI:1578667994
Name:MAINE MOLECULAR IMAGING LLC
Entity Type:Organization
Organization Name:MAINE MOLECULAR IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP & CHIEF ACCOUNTING OFCR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:DRAZBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:9492-826-0000
Mailing Address - Street 1:PO BOX 414025
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-4025
Mailing Address - Country:US
Mailing Address - Phone:949-282-6000
Mailing Address - Fax:
Practice Address - Street 1:27 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-5820
Practice Address - Country:US
Practice Address - Phone:800-734-4132
Practice Address - Fax:800-273-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME327079Medicare PIN