Provider Demographics
NPI:1710297494
Name:MAINEHEALTH
Entity Type:Organization
Organization Name:MAINEHEALTH
Other - Org Name:MAINE MEDICAL PARTNERS UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE 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 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-6562
Mailing Address - Fax:
Practice Address - Street 1:100 BRICKHILL AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-773-1728
Practice Address - Fax:207-772-4062
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAINE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-15
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208800000X, 363A00000X, 363LF0000X
ME37563282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME200009Medicare Oscar/Certification