Provider Demographics
NPI:1144342585
Name:PHYSICAL REHABILITATION OF SOUTHERN MAINE PC
Entity type:Organization
Organization Name:PHYSICAL REHABILITATION OF SOUTHERN MAINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-854-1544
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04098-0810
Mailing Address - Country:US
Mailing Address - Phone:207-854-1544
Mailing Address - Fax:207-854-1516
Practice Address - Street 1:335 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2362
Practice Address - Country:US
Practice Address - Phone:207-497-2996
Practice Address - Fax:207-497-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-05
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME014605208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1098OtherMEDICARE IND #
ME1811907199OtherINDIVIDUAL NPI #
ME$$$$$$$$$OtherSOCIAL SECURITY #
ME061235OtherANTHEM
ME0003023Medicare PIN
ME=========OtherTAX ID #