Basic Information
Provider Information | |||||||||
NPI: | 1386652535 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAINE BEHAVIORAL HEALTHCARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPRING HARBOR COMMUNITY SERVICES | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 78 ATLANTIC PL | ||||||||
Address2: |   | ||||||||
City: | SOUTH PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041062316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078427701 | ||||||||
FaxNumber: | 2078427773 | ||||||||
Practice Location | |||||||||
Address1: | 12 UNION ST | ||||||||
Address2: |   | ||||||||
City: | ROCKLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 048412739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077014400 | ||||||||
FaxNumber: | 2077014485 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2006 | ||||||||
LastUpdateDate: | 06/10/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOWERS | ||||||||
AuthorizedOfficialFirstName: | GREG | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP & COO | ||||||||
AuthorizedOfficialTelephone: | 2072532629 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X | 680905 | ME | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 132610002 | 05 | ME |   | MEDICAID | 435657000 | 05 | ME |   | MEDICAID | 435657002 | 05 | ME |   | MEDICAID | 132610001 | 05 | ME |   | MEDICAID | 435657001 | 05 | ME |   | MEDICAID | 435793101 | 05 | ME |   | MEDICAID | 132610000 | 05 | ME |   | MEDICAID | 435793100 | 05 | ME |   | MEDICAID |