Provider Demographics
NPI:1710061494
Name:MAINE DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MAINE DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-230-1007
Mailing Address - Street 1:2239 ATLANTIC HWY
Mailing Address - Street 2:
Mailing Address - City:LINCOLNVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04849-5310
Mailing Address - Country:US
Mailing Address - Phone:207-230-1007
Mailing Address - Fax:207-230-1008
Practice Address - Street 1:2239 ATLANTIC HWY
Practice Address - Street 2:
Practice Address - City:LINCOLNVILLE
Practice Address - State:ME
Practice Address - Zip Code:04849-5310
Practice Address - Country:US
Practice Address - Phone:207-230-1007
Practice Address - Fax:207-230-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1822207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME0826Medicare ID - Type Unspecified