Provider Demographics
NPI:1194077602
Name:GREATER PORTLAND HEARING PC
Entity type:Organization
Organization Name:GREATER PORTLAND HEARING PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:IACUESSA
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:207-846-1380
Mailing Address - Street 1:163 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-6720
Mailing Address - Country:US
Mailing Address - Phone:207-846-1380
Mailing Address - Fax:207-846-9701
Practice Address - Street 1:163 MAIN ST
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6720
Practice Address - Country:US
Practice Address - Phone:207-846-1380
Practice Address - Fax:207-846-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP1251237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1063586907OtherNPI
ME274460099Medicaid
ME274460099Medicaid