Provider Demographics
NPI:1619197423
Name:MAINE PEDIATRIC SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:MAINE PEDIATRIC SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TEMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:207-662-5866
Mailing Address - Street 1:887 CONGRESS ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3100
Mailing Address - Country:US
Mailing Address - Phone:207-662-5555
Mailing Address - Fax:207-662-5065
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-662-5555
Practice Address - Fax:207-662-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5342Medicare ID - Type UnspecifiedGROUP ID