Provider Demographics
NPI:1942388418
Name:INTERMED PA
Entity Type:Organization
Organization Name:INTERMED PA
Other - Org Name:INTERMED AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:FERENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-523-3648
Mailing Address - Street 1:100 GANNETT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 1000
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2443
Practice Address - Country:US
Practice Address - Phone:207-347-2898
Practice Address - Fax:207-553-1415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMED PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME38444261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECC4863OtherRR MEDICARE
ME126390100Medicaid
ME201012Medicare PIN
ME201012Medicare PIN