Provider Demographics
NPI:1699776146
Name:STATE OF MAINE
Entity type:Organization
Organization Name:STATE OF MAINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:WEBB
Authorized Official - Last Name:CODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-941-4192
Mailing Address - Street 1:109 CAPITOL STREET
Mailing Address - Street 2:STATE HOUSE STATION #11, REIMBURSEMENT UNIT
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-6846
Mailing Address - Country:US
Mailing Address - Phone:207-287-7418
Mailing Address - Fax:207-287-1862
Practice Address - Street 1:656 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5609
Practice Address - Country:US
Practice Address - Phone:207-941-4192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME135910900Medicaid
ME003288OtherBLUE CROSS
204004Medicare ID - Type Unspecified