Provider Demographics
NPI:1881767846
Name:MAINE EAR NOSE & THROAT CENTER LLC
Entity type:Organization
Organization Name:MAINE EAR NOSE & THROAT CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-885-0200
Mailing Address - Street 1:PO BOX 6490
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04070-6490
Mailing Address - Country:US
Mailing Address - Phone:207-885-0200
Mailing Address - Fax:207-885-0255
Practice Address - Street 1:69 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9374
Practice Address - Country:US
Practice Address - Phone:207-885-0200
Practice Address - Fax:207-885-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME014566207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9092Medicare ID - Type UnspecifiedMEDICARE NUMBER