Provider Demographics
NPI:1053596676
Name:CITY OF PORTLAND
Entity type:Organization
Organization Name:CITY OF PORTLAND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR ACCOUNTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:J
Authorized Official - Last Name:WATERHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-775-7911
Mailing Address - Street 1:196 LANCASTER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2418
Mailing Address - Country:US
Mailing Address - Phone:207-775-7911
Mailing Address - Fax:207-775-7918
Practice Address - Street 1:196 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2418
Practice Address - Country:US
Practice Address - Phone:207-775-7911
Practice Address - Fax:207-775-7918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME761251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME136040501Medicaid
ME136040500Medicaid