Provider Demographics
NPI:1134148331
Name:CITY OF SOUTH PORTLAND
Entity type:Organization
Organization Name:CITY OF SOUTH PORTLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMS COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:EMT P
Authorized Official - Phone:207-799-3314
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-1810
Mailing Address - Country:US
Mailing Address - Phone:207-892-0020
Mailing Address - Fax:207-893-0583
Practice Address - Street 1:684 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4407
Practice Address - Country:US
Practice Address - Phone:207-797-3314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME6553416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME590000162OtherRAILROAD MEDICARE
ME001173OtherBLUE CROSS
ME136070000Medicaid
ME590000162OtherRAILROAD MEDICARE