Provider Demographics
NPI:1306963491
Name:SOUTHERN MAINE ALLERGY ASSOCIATES, PA
Entity type:Organization
Organization Name:SOUTHERN MAINE ALLERGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:VASSILY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIHAILOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-284-6114
Mailing Address - Street 1:1050 WALL ST W STE 360
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071-3604
Mailing Address - Country:US
Mailing Address - Phone:201-821-7900
Mailing Address - Fax:
Practice Address - Street 1:28 W COLE RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9428
Practice Address - Country:US
Practice Address - Phone:207-284-6114
Practice Address - Fax:207-282-6118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME125300000Medicaid
MEMM0569Medicare ID - Type Unspecified