Provider Demographics
NPI:1174519490
Name:NORTHERN MAINE MEDICAL CENTER
Entity type:Organization
Organization Name:NORTHERN MAINE MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZEWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-834-1411
Mailing Address - Street 1:25 BOLDUC AVE
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1601
Mailing Address - Country:US
Mailing Address - Phone:207-834-3915
Mailing Address - Fax:207-834-5538
Practice Address - Street 1:25 BOLDUC AVE
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1601
Practice Address - Country:US
Practice Address - Phone:207-834-3915
Practice Address - Fax:207-834-5538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36151313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1174519490Medicaid
ME031150OtherANTHEM BLUE CROSS & BS
=========016OtherTRICARE INSURANCE
205176Medicare ID - Type Unspecified