Provider Demographics
NPI:1225886039
Name:MAINE OPIOID DEPENDENCY PROGRAM
Entity type:Organization
Organization Name:MAINE OPIOID DEPENDENCY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-405-1474
Mailing Address - Street 1:219 ROYALL POINT RD
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-5762
Mailing Address - Country:US
Mailing Address - Phone:207-229-2190
Mailing Address - Fax:
Practice Address - Street 1:114 STROUDWATER ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4037
Practice Address - Country:US
Practice Address - Phone:207-405-1474
Practice Address - Fax:207-283-9357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty