Provider Demographics
NPI:1285703025
Name:MAINE REHABILITATIVE HEALTHCARE, LLC
Entity type:Organization
Organization Name:MAINE REHABILITATIVE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-883-3434
Mailing Address - Street 1:306 US ROUTE 1
Mailing Address - Street 2:BUILDING B SOUTH
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7640
Mailing Address - Country:US
Mailing Address - Phone:207-883-3434
Mailing Address - Fax:207-883-1424
Practice Address - Street 1:306 US ROUTE 1
Practice Address - Street 2:BUILDING B SOUTH
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7640
Practice Address - Country:US
Practice Address - Phone:207-883-3434
Practice Address - Fax:207-883-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1432208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME178380000Medicaid
ME178380000Medicaid
MEF63293Medicare UPIN