Provider Demographics
NPI:1891810412
Name:MAINE CENTERS FOR HEALTHCARE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MAINE CENTERS FOR HEALTHCARE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTORY
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:PICKUS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-857-9311
Mailing Address - Street 1:980 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3336
Mailing Address - Country:US
Mailing Address - Phone:207-347-7853
Mailing Address - Fax:207-347-7855
Practice Address - Street 1:980 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3336
Practice Address - Country:US
Practice Address - Phone:207-347-7853
Practice Address - Fax:207-347-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM8478Medicare ID - Type Unspecified