Provider Demographics
NPI: | 1790889376 |
---|---|
Name: | MAINE MEDICAL PARTNERS |
Entity Type: | Organization |
Organization Name: | MAINE MEDICAL PARTNERS |
Other - Org Name: | MMC ORAL SURGERY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | STEPHEN |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | KASABIAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 207-761-0650 |
Mailing Address - Street 1: | 39 WALLACE AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | SOUTH PORTLAND |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04106-6143 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 207-761-0650 |
Mailing Address - Fax: | 207-761-8198 |
Practice Address - Street 1: | 22 BRAMHALL ST |
Practice Address - Street 2: | DEPT OF SURGERY |
Practice Address - City: | PORTLAND |
Practice Address - State: | ME |
Practice Address - Zip Code: | 04102-3134 |
Practice Address - Country: | US |
Practice Address - Phone: | 207-871-4078 |
Practice Address - Fax: | 207-871-6389 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-09-12 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 204E00000X | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | Group - Single Specialty |