SPECTRUM HEALTHCARE PARTNERS, PA

Provider Demographics

• NPI: 1669488011
• Name: SPECTRUM HEALTHCARE PARTNERS, PA
• Entity Type: Organization
• Organization Name: SPECTRUM HEALTHCARE PARTNERS, PA
• Other - Org Name: SPECTRUM MEDICAL GROUP, PA
• Other - Org Type: Former Legal Business Name
• Authorized Official - Title/Position: CEO
• Authorized Official - First Name: DAVID
• Authorized Official - Middle Name: B
• Authorized Official - Last Name: LANDRY
• Authorized Official - Phone: 207-482-7800
• Mailing Address - Street 1: PO BOX 95000 LB#7810
• Mailing Address - City: PHILADELPHIA
• Mailing Address - State: PA
• Mailing Address - Zip Code: 19195-0001
• Mailing Address - Country: US
• Mailing Address - Phone: 844-947-4259
• Mailing Address - Fax: 302-261-8368
• Practice Address - Street 1: 22 BRAMHALL ST
• Practice Address - City: PORTLAND
• Practice Address - State: ME
• Practice Address - Zip Code: 04102-3134
• Practice Address - Country: US
• Practice Address - Phone: 207-662-2571
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: SPECTRUM HEALTHCARE PARTNERS, PA
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2006-07-31
• Last Update Date: 2022-02-16

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	2085R0202X	Allopathic & Osteopathic Physicians	Radiology	Diagnostic Radiology	Group - Multi-Specialty
No	2085R0001X	Allopathic & Osteopathic Physicians	Radiology	Radiation Oncology	Group - Multi-Specialty
No	2085R0204X	Allopathic & Osteopathic Physicians	Radiology	Vascular & Interventional Radiology	Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
ME	1669488011	Medicaid
MA	0000Z48460	Other	MA ANTHEM
ME	130560016	Medicaid
ME	130560027	Medicaid
ME	130560017	Medicaid
ME	130560026	Medicaid
ME	2547081	Other	AETNA PHO
ME	130560056	Medicaid
NH	30010301	Medicaid
ME	1044567	Other	AETNA NON PHO
ME	S0528	Other	ANTHEM
ME	M108750	Other	CIGNA
ME	130560055	Medicaid
ME	130560003	Medicaid
ME	130560035	Medicaid
ME	130560003	Medicaid
MA	0000Z48460	Other	MA ANTHEM
ME	CC5457	Medicare ID - Type Unspecified	RAILROAD
ME	130560027	Medicaid
ME	130560017	Medicaid
MA	0011618	Medicare PIN