Provider Demographics
NPI:1689799504
Name:CITY OF PORTLAND MAINE
Entity Type:Organization
Organization Name:CITY OF PORTLAND MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUBLIC HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALFERDO
Authorized Official - Middle Name:E
Authorized Official - Last Name:VERGARA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD EPIDEMIOLOGIST
Authorized Official - Phone:207-956-4013
Mailing Address - Street 1:39 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2912
Mailing Address - Country:US
Mailing Address - Phone:207-874-8446
Mailing Address - Fax:
Practice Address - Street 1:39 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2912
Practice Address - Country:US
Practice Address - Phone:207-874-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEH80CS00005-04-00261QF0400X
261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME136040602Medicaid