Basic Information
| Provider Information | |||||||||
| NPI: | 1982649158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW ENGLAND MOLECULAR IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 BAYVIEW CIRCLE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926602984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005443215 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 MAIN ST | ||||||||
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| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077950111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | LONGMORE GRUND | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 8005443215 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0208X | 01601 | ME | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile |
ID Information
| ID | Type | State | Issuer | Description | 7695348 | 01 | ME | AETNA | OTHER | 129019400 | 01 | ME | U.S. DEPT OF LABOR OWCP | OTHER | 166060000 | 05 | ME | MEDICAID | 043913 | 01 | ME | ANTHEM BLUE CROSS | OTHER | 800942 | 01 | ME | HARVARD PILGRIM HLTH CARE | OTHER |