Provider Demographics
NPI:1578690848
Name:CENTRAL MAINE ORTHOPAEDICS AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:CENTRAL MAINE ORTHOPAEDICS AMBULATORY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-783-1328
Mailing Address - Street 1:690 MINOT AVE
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-3922
Mailing Address - Country:US
Mailing Address - Phone:207-783-1315
Mailing Address - Fax:207-786-3576
Practice Address - Street 1:690 MINOT AVE
Practice Address - Street 2:SUITE ONE
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3922
Practice Address - Country:US
Practice Address - Phone:207-783-1315
Practice Address - Fax:207-786-3576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 208100000X, 213ES0103X
ME36418261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME116640200OtherMAINECARE
MM0716OtherMEDICARE