Provider Demographics
NPI:1962422964
Name:MAINE BEHAVIORAL HEALTHCARE
Entity type:Organization
Organization Name:MAINE BEHAVIORAL HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP & COO
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-253-2629
Mailing Address - Street 1:78 ATLANTIC PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-842-7701
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:165 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2406
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME680905251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104760000Medicaid
ME104760001Medicaid
ME104760201Medicaid
ME104760100Medicaid
ME14760200Medicaid
ME14760200Medicaid
MEMM3042Medicare PIN