Provider Demographics
NPI:1699875674
Name:SOUTHERN MAINE PHYSICAL THERAPY
Entity type:Organization
Organization Name:SOUTHERN MAINE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYRE
Authorized Official - Suffix:
Authorized Official - Credentials:PT/OWNER
Authorized Official - Phone:207-799-9700
Mailing Address - Street 1:449 COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4924
Mailing Address - Country:US
Mailing Address - Phone:207-799-9700
Mailing Address - Fax:207-799-9706
Practice Address - Street 1:449 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4924
Practice Address - Country:US
Practice Address - Phone:207-799-9700
Practice Address - Fax:207-799-9706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
ME225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2433023OtherAETNA GROUP NUMBER
ME040910OtherANTHEM GROUP NUMBER
ME100482300OtherDEPT OF LABOR WKERS COMP
ME130470100Medicaid
MEDB3088OtherMEDICARE RAILROAD
MEMNT112OtherHARVARD PILGRIM
ME5182235OtherCIGNA HEALTH CARE
ME130470100Medicaid