Provider Demographics
NPI:1710218078
Name:MAINEHEALTH
Entity Type:Organization
Organization Name:MAINEHEALTH
Other - Org Name:MAINE MEDICAL CENTER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCAITE CFO
Authorized Official - Prefix:
Authorized Official - First Name:LUGENE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:INZANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-662-3538
Mailing Address - Street 1:300 SOUTHBOROUGH DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:272 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-874-2466
Practice Address - Fax:207-774-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432747700Medicaid