Covered Entity Details

DSH200009CM MAINEHEALTH MAINE MEDICAL CENTER (Active) - information as of 4/25/2025 9:21:22 PM

Main Details

Name

MAINEHEALTH MAINE MEDICAL CENTER

Subdivision Name

MMP Dermatology

Type

Disproportionate Share Hospital

Rural

340B ID

DSH200009CM

Medicare Provider Number

200009

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/15/2020

Participating Start Date

4/1/2020

Participating Approval Date

2/11/2020

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

MaineHealth
Chris Coon, Southern Region Vice President, Finance
(207) 662-6213

Primary Contact

MaineHealth
BRIAN MARDEN, Chief Pharmacy Officer
(207) 661-3057

Addresses

Street Address

1601 Congress Street
Portland, ME 04102

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
ME		1760436216,1376981993

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH200009A	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Gilman Clinic	48-52 GILMAN STREET	PORTLAND	ME	Active
DSH200009AA	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Cape Elizabeth Internal Medicine	155 Spurwink Ave	Cape Elizabeth	ME	Active
DSH200009AB	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Falmouth Internal Medicine	5 Bucknam Road	Falmouth	ME	Active
DSH200009AC	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Scarborough Internal Medicine	49 Spring Street	Scarborough	ME	Active
DSH200009AD	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Westbrook Internal Medicine	1 Harnois Avenue	Westbrook	ME	Active
DSH200009AE	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Lakes Region Primary Care	582 Roosevelt Trail	Windham	ME	Active
DSH200009AF	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Westbrook Family Medicine	1 Harnois Avenue	Westbrook	ME	Active
DSH200009AG	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Scarborough Family Medicine	49 Spring Street	Scarborough	ME	Active
DSH200009AH	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Women's Health - Division of Gynecologic Oncology	100 Campus Drive, Suite 125	Scarborough	ME	Active
DSH200009AJ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Women's Health - Endocrinology & Infertility	887 Congress Street, Suite 200	Portland	ME	Active
DSH200009AK	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Women's Health - Division of Urogynecology	100 Brickhill Ave. Suite 203	South Portland	ME	Active
DSH200009AL	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Neurosurgery and Spine	92 Campus Drive	Scarborough	ME	Active
DSH200009AM	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Spine Center	92 Campus Drive	Scarborough	ME	Active
DSH200009AN	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Urology	100 Brickhill Ave. Suite 100	South Portland	ME	Active
DSH200009AP	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Endocrinology	175 US Route 1	Scarborough	ME	Active
DSH200009AQ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Diabetes Center	175 US Route 1	Scarborough	ME	Active
DSH200009AR	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Adult and Pediatric Neurology	92 Campus Drive	Scarborough	ME	Active
DSH200009AS	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Maine Children's Cancer Program	100 Campus Drive, Unit 107	Scarborough	ME	Active
DSH200009AT	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Orthopedic Trauma & Fracture Care	335 Brighton Ave. Suite 200	Portland	ME	Active
DSH200009AU	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Otolaryngology (ENT)	92 Campus Drive	Scarborough	ME	Active
DSH200009AV	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Ambulatory Diagnostic Services - Vascular Center	84 Campus Drive	Scarborough	ME	Active
DSH200009AW	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Neuro Spine	92 Campus Drive	Scarborough	ME	Active
DSH200009AX	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Developmental/Behavioral Health	1577 Congress Street	Portland	ME	Active
DSH200009AY	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Ambulatory Clinic Services - Breast Care	100 Campus Drive	Scarborough	ME	Active
DSH200009AZ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MRI - Diagnostic Center	100 Campus Drive	Scarborough	ME	Active
DSH200009B	Child	DSH	MAINE MEDICAL CENTER	VASCULAR CENTER	131 CHADWICK STREET	PORTLAND	ME	Terminated
DSH200009BA	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Radiation Therapy Services - Oncology Admin	100 Campus Drive	Scarborough	ME	Active
DSH200009BB	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Radiation Therapy Services - Coastal Cancer	175 Congress Ave	Bath	ME	Active
DSH200009BC	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Diagnostic Center - Falmouth	5 Bucknam Road	Falmouth	ME	Active
DSH200009BD	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Mental Health Services - Adult	216 Vaughan St	Portland	ME	Active
DSH200009BE	Child	DSH	MAINE MEDICAL CENTER	Mental Health Services - Child	216 Vaughan St.	Portland	ME	Terminated
DSH200009BF	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Geriatrics Center	66 Bramhall St	Portland	ME	Active
DSH200009BG	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMC Sleep Institute	930 Congress Street	Portland	ME	Active
DSH200009BH	Child	DSH	MAINE MEDICAL CENTER	OPD HIV Treatment Center	48-52 Gilman Street	Portland	ME	Terminated
DSH200009BJ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Ambulatory Surgical Services	84 Campus Drive	Scarborough	ME	Active
DSH200009BK	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Ambulatory Diagnostic Services	100 Campus Drive	Scarborough	ME	Active
DSH200009BL	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Turning Point - Cardiac Rehab	96 Campus Drive	Scarborough	ME	Active
DSH200009BM	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Orthopedics - Division of Joint Replacements	5 Bucknam Road, Suite D1	Falmouth	ME	Active
DSH200009BP	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP MaineHealth Cardiology Lewiston	99 Campus Avenue	Lewiston	ME	Active
DSH200009BQ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP - MaineHealth Cardiology Scarborough	96 Campus Drive	Scarborough	ME	Active
DSH200009BR	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Family Medicine - Sports Medicine	272 Congress Street	Portland	ME	Active
DSH200009BS	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Peak's Island Family Medicine	87 Central Avenue	Peak's Island	ME	Active
DSH200009BT	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Brighton Medical Center - ASC - Diagnostic Exam Room	335 Brighton Avenue	Portland	ME	Active
DSH200009BU	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Brighton Medical Center - CT Scan	335 Brighton Avenue	Portland	ME	Active
DSH200009BV	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Scarborough Nuclear Medicine	100 Campus Drive	Scarborough	ME	Active
DSH200009BW	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Scarborough Imaging	100 Campus Drive	Scarborough	ME	Active
DSH200009BX	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Scarborough Ultra Sound	100 Campus Drive	Scarborough	ME	Active
DSH200009BY	Child	DSH	MAINE MEDICAL CENTER	MMP MRI	49 Spring Street	Scarborough	ME	Terminated
DSH200009BZ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Falmouth Family Medicine	5 Bucknam Road	Falmouth	ME	Active
DSH200009C	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MENTAL HEALTH SERVICES	66 BRAMHALL ST.	PORTLAND	ME	Active
DSH200009CA	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Thoracic Oncology Clinic	100 Campus Drive	Scarborough	ME	Active
DSH200009CB	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Orthopedics & Sports Medicine	119 Gannett Drive	South Portland	ME	Active
DSH200009CC	Child	DSH	MAINE MEDICAL CENTER	MMC Surgical Care	92 Campus Drive	Scarborough	ME	Terminated
DSH200009CD	Child	DSH	MAINE MEDICAL CENTER	MMC Biddeford IV Therapy	26 West Cole Road	Biddeford	ME	Terminated
DSH200009CE	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMC Sanford IV Therapy	27 Industrial Avenue	Sanford	ME	Active
DSH200009CF	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Cardiovascular Surgery	818 Congress Street	Portland	ME	Active
DSH200009CG	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Pediatric Neurology (P Neurology General)	92 Campus Drive	SCARBOROUGH	ME	Active
DSH200009CH	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP OP - Oncology	265 Western Avenue	South Portland	ME	Active
DSH200009CJ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	South Portland IV Therapy - Intravenous Therapy	265 Western Avenue	South Portland	ME	Active
DSH200009CK	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Congenital Heart - Congential Heart	71 US Route 1	SCARBOROUGH	ME	Active
DSH200009CL	Child	DSH	MAINE MEDICAL CENTER	Medical Oncology Biddeford - Oncology	26 West Cole Rd	Biddefod	ME	Terminated
DSH200009CM	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Dermatology	1601 Congress Street	Portland	ME	Active
DSH200009CN	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Medical Oncology Sanford - Oncology	27 Industrial Avenue	Sanford	ME	Active
DSH200009CP	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Adult Infectious Disease - Infectious Disease	41 Donald Dean Dr	South Portland	ME	Active
DSH200009CQ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Vascular Surgery - Vascular Surgery	92 Campus Drive	Scarborough	ME	Active
DSH200009CR	Child	DSH	MAINE MEDICAL CENTER	MMP General Surgery, Trauma and Critical Care - Surgery	79 Bramhall Street	Portland	ME	Terminated
DSH200009CS	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Brunswick IV Therapy - Outpatient IV Therapy	329 Maine St	Brunswick	ME	Active
DSH200009CT	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Ortho Sports Windham - Ortho and Sports Medicine	584 Roosevelt Trail	Windham	ME	Active
DSH200009CU	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Standish Primary Care - Primary Care	111 Ossipee Trail East	Standish	ME	Active
DSH200009CV	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP PSC - Gender Clinic - Gender Clinic	1577 Congress Street	Portland	ME	Active
DSH200009CW	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Palliative Care Clinic - Palliative Care	144 Us Route 1	Scarborough	ME	Active
DSH200009CX	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Otolaryngology Procedure Biddeford - Otolaryngology	30 West Cole Rd	Biddeford	ME	Active
DSH200009CY	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Women's Health Division of Maternal Fetal Medicine - Women's Health	887 Congress St	Portland	ME	Active
DSH200009CZ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP SURGICAL CARE CASCO BAY - Surgery	55 SPRING STREET	SCARBOROUGH	ME	Active
DSH200009DA	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Surgical Care - General Surgery	887 Congress St	Portland	ME	Active
DSH200009DB	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Surgical Oncology - Surgery Oncology	887 Congress St	Portland	ME	Active
DSH200009DC	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Otolaryngology Biddeford - Otolaryngology	30 West Cole Rd	Biddeford	ME	Active
DSH200009DD	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP NEPHROLOGY - Nephrology	1600B CONGRESS ST	PORTLAND	ME	Active
DSH200009DE	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Comprehensive Addiction Medicine - Portland - Comprehensive Addiction Medicine - Portland	576 St. John Street	Portland	ME	Active
DSH200009DF	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Sleep Medicine Kennebunk - Sleep Medicine	2 Livewell Dr. - South Tower	Kennebunk	ME	Approved
DSH200009DG	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pediatric Specialty Care Developmental Medicine Kennebunk - Pediatrics	3 Shape Dr	Kennebunk	ME	Approved
DSH200009DH	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Walk-In Care - East Waterboro - Walk-In Care	10 Goodall Dr.	East Waterboro	ME	Approved
DSH200009DJ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Walk-In Care - Kennebunk - Walk-In Care	2 Livewell Dr. - North Tower	Kennebunk	ME	Approved
DSH200009DK	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Primary Care- Family Medicine- Saco - Primary Care	13 Industrial Park Rd.	Saco	ME	Approved
DSH200009DL	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Infectious Disease Biddeford - Infectious Diseases	46 Barra Road	Biddeford	ME	Approved
DSH200009DM	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Wound Care - Biddeford - Wound Care	1 Medical Center Dr.	Biddeford	ME	Approved
DSH200009DN	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Anesthesia Virtual - Anesthesia	25 June St	Sanford	ME	Approved
DSH200009DP	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Primary Care- Internal Medicine- Biddeford - Primary Care	46 Barra Rd.	Biddeford	ME	Approved
DSH200009DQ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Radiology Ultrasound Healthcare Dr Biddeford - Ultrasound	9 Healthcare Dr	Biddeford	ME	Approved
DSH200009DR	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth DXA Sanford - Radiology	25A June St	Sanford	ME	Approved
DSH200009DS	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Radiology X-ray Saco - Radiology	655 Main St.	Saco	ME	Approved
DSH200009DT	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Radiology MRI - MRI	25 June St	Sanford	ME	Approved
DSH200009DU	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Radiology Mammography - Radiology	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009DV	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Radiology Interventional Radiology - Radiology	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009DW	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Radiology MRI - MRI	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009DX	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Radiology CT Scan - CT Scan	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009DY	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Radiology Nuclear Medicine - Nuclear Medicine	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009DZ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Vascular Surgery Radiology Ultrasound Biddeford - Ultrasound	9 Healthcare Dr	Biddeford	ME	Approved
DSH200009E	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	SCARBOROUGH OUTPATIENT IV THERAPY DEPARTMENT	100 CAMPUS DRIVE, SUITE 124	SCARBOROUGH	ME	Active
DSH200009EA	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth DXA Healthcare Dr Biddeford - Radiology	9 Healthcare Dr	Biddeford	ME	Approved
DSH200009EB	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Radiology Care Unit - Scarborough - Radiology	100 Campus Drive	Scarborough	ME	Approved
DSH200009EC	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Radiology Ultrasound - Ultrasound	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009ED	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Orthopedics and Sports Medicine Radiology X-Ray Sanford - Radiology	25A June St.	Sanford	ME	Approved
DSH200009EE	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Radiology X-ray Barra Rd Biddeford - Radiology	46 Barra Rd	Biddeford	ME	Approved
DSH200009EF	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Gastroenterology Biddeford - Gastroenterology	9 Healthcare Dr.	Biddeford	ME	Approved
DSH200009EG	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Post Anesthesia Care Unit - Post Anesthesia Care Unit	25 June St	Sanford	ME	Approved
DSH200009EH	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Post Anesthesia Care Unit - Post Anesthesia Care Unit	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009EJ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Neurology - Biddeford - Neurology	46 Barra Rd.	Biddeford	ME	Approved
DSH200009EK	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Health Center - Kennebunk - Primary Care	2 Livewell Dr. North Tower	Kennebunk	ME	Approved
DSH200009EL	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Preble Street Learning Collaborative Portland - Primary Care	20 Portland St	Portland	ME	Approved
DSH200009EM	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Dermatology - Kennebunk - Dermatology	2 Livewell Dr	Kennebunk	ME	Approved
DSH200009EN	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Primary Care- Family Medicine- Sanford - Primary Care	25A June St.	Sanford	ME	Approved
DSH200009EP	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pediatrics - Biddeford - Pediatrics	9 Healthcare Dr.	Biddeford	ME	Approved
DSH200009EQ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pediatrics - Kennebunk - Pediatrics	3 Shape Dr.	Kennebunk	ME	Approved
DSH200009ER	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pediatrics - Main St - Saco - Pediatrics	655 Main St	Saco	ME	Approved
DSH200009ES	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pediatrics - Sanford - Pediatrics	25 June St.	Sanford	ME	Approved
DSH200009ET	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Walk-In Care - Sanford - Walk-In Care	25A June St.	Sanford	ME	Approved
DSH200009EU	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Weight Management - Kennebunk - Weight Management	72 Main St.	Kennebunk	ME	Approved
DSH200009EV	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Cancer Care and IV Therapy - Brunswick - Oncology	329 Maine Street	Brunswick	ME	Approved
DSH200009EW	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Walk-In Care - Saco - Walk-In Care	655 Main St.	Saco	ME	Approved
DSH200009EX	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Vascular Surgery - Biddeford - Vascular Surgery	9 Healthcare Dr	Biddeford	ME	Approved
DSH200009EY	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Endoscopy - Endoscopy	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009EZ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Operating Room - Operating Room	25 June St	Sanford	ME	Approved
DSH200009F	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	Maine Medical Center Urgent Care Plus	335 BRIGHTON AVENUE	PORTLAND	ME	Active
DSH200009FA	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Emergency Department - Emergency Care	25 June St	Sanford	ME	Approved
DSH200009FB	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Cardiology Cath Lab - Cath Lab	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009FC	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Sports Performance and Physical Therapy Saco - Sports Medicine	12 Thornton Ave.	Saco	ME	Approved
DSH200009FD	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Sports Performance Sanford - Sports Medicine	1 Emile Levasseur Dr	Sanford	ME	Approved
DSH200009FE	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Cardiopulmonary Care - Pulmonary Medicine	1 Medical Center Dr.	Biddeford	ME	Approved
DSH200009FF	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Anesthesia Virtual - Anesthesia	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009FG	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Radiology - Radiology	25 June St	Sanford	ME	Approved
DSH200009FH	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Sleep Medicine - Sleep Lab - Kennebunk - Sleep Lab	2 Livewell Dr. - South Tower	Kennebunk	ME	Approved
DSH200009FJ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Cardiology- Sanford - Cardiology	25A June St	Sanford	ME	Approved
DSH200009FK	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Cardiology - Biddeford - Cardiology	9 Healthcare Dr.	Biddeford	ME	Approved
DSH200009FL	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pulmonary and Sleep Medicine - Sanford - Pulmonary and Sleep Medicine	25A June St.	Sanford	ME	Approved
DSH200009FM	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Surgical Care - Biddeford - Surgical Care	9 Healthcare Dr.	Biddeford	ME	Approved
DSH200009FN	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Surgical Care Sanford - Surgical Care	25A June St.	Sanford	ME	Approved
DSH200009FP	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Occupational Health Sanford - Occupational Health	13 July Street	Sanford	ME	Approved
DSH200009FQ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Occupational Health/WorkWell Biddeford - Occupational Health	10 Wellspring Rd.	Biddeford	ME	Approved
DSH200009FR	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Operating Room - Operating Room	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009FS	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Orthopedics and Sports Medicine - Biddeford - Sports Medicine	46 Barra Rd.	Biddeford	ME	Approved
DSH200009FT	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Ambulatory Surgical Unit - Surgery	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009FU	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Respiratory Therapy - Respiratory Medicine	25 June St	Sanford	ME	Approved
DSH200009FV	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pulmonary and Sleep Medicine - Biddeford - Pulmonary and Sleep Medicine	9 Healthcare Dr	Biddeford	ME	Approved
DSH200009FW	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Orthopedics and Sports Medicine - Sanford - Sports Medicine	25A June St.	Sanford	ME	Approved
DSH200009FX	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center - Biddeford - Cardiopulmonary Rehab - Cardiac Rehab	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009FY	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Obstetrics and Gynecology- Biddeford - Women's Health	9 Healthcare Dr	Biddeford	ME	Approved
DSH200009FZ	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Cardiopulmonary Care Sanford - Pulmonary Medicine	25A June St	Sanford	ME	Approved
DSH200009G	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMC Weight and Wellness	41 Donald B. Dean Drive	South Portland	ME	Active
DSH200009GA	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Obstetrics and Gynecology - Family Birth Center- Biddeford - Women's Health	1 Medical Center Dr.	Biddeford	ME	Approved
DSH200009GB	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pain Care - Sanford - Pain Clinic	25A June St.	Sanford	ME	Approved
DSH200009GC	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Pain Care - Kennebunk - Pain Clinic	2 Livewell Dr- South Tower	Kennebunk	ME	Approved
DSH200009GD	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Obstetrics and Gynecology - Sanford - Women's Health	25A June St	Sanford	ME	Approved
DSH200009GE	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Sanford Radiology Ultrasound - Ultrasound	25 June St	Sanford	ME	Approved
DSH200009GF	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Emergency Department - Emergency Care	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009GG	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MaineHealth Maine Medical Center Biddeford Emergency Department Radiology Ultrasound - Emergency Care Radiology	1 Medical Center Dr	Biddeford	ME	Approved
DSH200009H	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	KIDNEY TRANSPLANT PROGRAM	43 Baxter Boulevard	PORTLAND	ME	Active
DSH200009J	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	FAMILY MEDICINE CENTER PROGRAMS	272 CONGRESS ST.	PORTLAND	ME	Active
DSH200009K	Child	DSH	MAINE MEDICAL CENTER	FALMOUTH CAMPUS - AMBULATORY CLINIC SERVICES	5 BUCKMAN ROAD	FALMOUTH	ME	Terminated
DSH200009L	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Falmouth Pediatrics	5 Bucknam Road, Suite 2A	Falmouth	ME	Active
DSH200009M	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Portland Pediatrics	1577 Congress Street	Portland	ME	Active
DSH200009N	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Saco Pediatrics	4 Scamman Street, Suite 51	Saco	ME	Active
DSH200009P	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP South Portland Pediatrics	75 John Roberts Road	South Portland	ME	Active
DSH200009Q	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Westbrook Pediatrics	1 Harnois Avenue	Westbrook	ME	Active
DSH200009R	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Pulmonary	887 Congress Street Suite 320	Portland	ME	Active
DSH200009S	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Infectious Diseases	887 Congress Street Suite 320	Portland	ME	Active
DSH200009T	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Diabetes	887 Congress Street, Suite 100	Portland	ME	Active
DSH200009U	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Endocrinology	887 Congress Street, Suite B120	Portland	ME	Active
DSH200009V	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Gastroenterology	887 Congress Street, Suite 300	Portland	ME	Active
DSH200009W	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Nephrology	887 Congress Street, Suite 300	Portland	ME	Active
DSH200009X	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Genetics	1577 Congress Street	Portland	ME	Active
DSH200009Y	Child	DSH	MAINE MEDICAL CENTER	MMP Pediatric Specialty Care - Countdown Clinic	1577 Congress Street	Portland	ME	Terminated
DSH200009Z	Child	DSH	MAINEHEALTH MAINE MEDICAL CENTER	MMP Pediatric Surgery	887 Congress Street, Suite 400	Portland	ME	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Entity Name	Update	Change Request	MAINE MEDICAL CENTER	MAINEHEALTH MAINE MEDICAL CENTER	3/26/2025 7:05 AM
Contacts	Authorizing Official	Update	Change Request	Inzana, Lugene Anthony CFO Maine Medical Center 2076622654	Coon, Chris Southern Region Vice President, Finance MaineHealth 2076626213	1/21/2025 7:56 AM
Contacts	Primary Contact	Update	Group Change Request	Tran, Roya Director of 340B Program & Drug Supply Management Maine Health 2076610304	MARDEN, BRIAN Chief Pharmacy Officer MaineHealth 2076613057	1/13/2025 3:02 PM
Details	Last Recertification Date	Update	Recertification	9/6/2023 11:34:22 AM	8/19/2024 12:23:24 PM	8/19/2024 12:23 PM
Contacts	Primary Contact	Update	Profile Change Request	Tran, Roya Director of 340B Program & Drug Supply Management Maine Health 2076613057	Tran, Roya Director of 340B Program & Drug Supply Management Maine Health 2076610304	8/16/2024 2:07 PM
Contacts	Primary Contact	Update	Group Change Request	MARDEN, BRIAN Chief Pharmacy Officer MaineHealth 2076613057	Tran, Roya Director of 340B Program & Drug Supply Management Maine Health 2076613057	7/31/2024 9:46 AM
Contacts	Primary Contact	Update	Group Change Request	Tran, Roya Director of 340B Program & Drug Supply Management Maine Health 2076613057	MARDEN, BRIAN Chief Pharmacy Officer MaineHealth 2076613057	2/9/2024 4:35 PM
Details	Last Recertification Date	Update	Recertification	9/6/2022 3:28:17 PM	9/6/2023 11:34:22 AM	9/6/2023 11:34 AM
Contacts	Primary Contact	Update	Group Change Request	MARDEN, BRIAN Chief Pharmacy Officer MaineHealth 2076613057	Tran, Roya Director of 340B Program & Drug Supply Management Maine Health 2076613057	8/15/2023 3:28 PM
Contacts	Primary Contact	Update	Group Change Request	Hoang, Minh Director of 340B and Drug Supply Management MaineHealth 7145101694	MARDEN, BRIAN Chief Pharmacy Officer MaineHealth 2076613057	1/4/2023 7:30 AM
Addresses	Main Address	Update	Change Request	265 Western Avenue Suite 1 South Portland, ME 04106	1601 Congress Street Portland, ME 04102	9/29/2022 1:53 PM
Contacts	Primary Contact	Update	Recertification	Marden, Brian Chief Pharmacy Officer MaineHealth 2076613057	Hoang, Minh Director of 340B and Drug Supply Management MaineHealth 7145101694	9/6/2022 3:28 PM
Details	Last Recertification Date	Update	Recertification	9/7/2021 4:38:21 PM	9/6/2022 3:28:17 PM	9/6/2022 3:28 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1376981993	1/29/2022 5:24 PM
Medicaid Billing	NPI: State	Insert	Change Request		ME	1/29/2022 5:24 PM
Details	Last Recertification Date	Update	Recertification	8/19/2020 12:30:36 PM	9/7/2021 4:38:21 PM	9/7/2021 4:38 PM
Details	Entity Subname	Update	Recertification	P Dermatology - Dermatology	MMP Dermatology	9/7/2021 4:38 PM
Medicaid Billing	NPI: State	Update	Recertification		ME	8/19/2020 12:30 PM
Details	Last Recertification Date	Update	Recertification		8/19/2020 12:30:36 PM	8/19/2020 12:30 PM
Addresses	Main Address	Update	Change Request	265 Western Avenue Suite 2 South Portland, ME 04106	265 Western Avenue Suite 1 South Portland, ME 04106	6/25/2020 8:47 AM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Inzana, Lugene Anthony CFO Maine Medical Center 2076622654	2/11/2020 6:55 AM
Details	340B ID	Update	New Registration		DSH200009CM	2/11/2020 6:55 AM
Details	Entity Subname	Update	New Registration	P Dermatology	P Dermatology - Dermatology	2/11/2020 6:55 AM
Dates	Participating Approval Date	Update	New Registration		2/11/2020 6:55:00 AM	2/11/2020 6:55 AM
Details	State	Update	New Registration	Pending	Approved	2/11/2020 6:55 AM
Dates	Signed By Date	Update	New Registration		1/29/2020 3:56:01 PM	2/11/2020 6:55 AM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	2/11/2020 6:55 AM
Addresses	Main Address	Insert	New Registration		265 Western Avenue Suite 2 South Portland, ME 04106	1/15/2020 3:43 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760436216	1/15/2020 3:43 PM
Contacts	Authorizing Official	Insert	New Registration		Inzana, Lugene Anthony CFO Maine Medical Center 2076622654	1/15/2020 3:43 PM
Contacts	Primary Contact	Insert	New Registration		Marden, Brian Chief Pharmacy Officer MaineHealth 2076613057	1/15/2020 3:43 PM
Details	Last Recertification Date	Insert	New Registration			1/15/2020 3:43 PM
Details	Grant Number	Insert	New Registration			1/15/2020 3:43 PM
Details	340B ID	Insert	New Registration			1/15/2020 3:43 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/15/2020 3:43 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/15/2020 3:43 PM
Details	Medicare Provider Number	Insert	New Registration		200009	1/15/2020 3:43 PM
Details	Entity Name	Insert	New Registration		MAINE MEDICAL CENTER	1/15/2020 3:43 PM
Details	Program Code	Insert	New Registration		DSH	1/15/2020 3:43 PM
Details	Entity Subname	Insert	New Registration		P Dermatology	1/15/2020 3:43 PM
Dates	Participating Approval Date	Insert	New Registration			1/15/2020 3:43 PM
Details	State	Insert	New Registration		Pending	1/15/2020 3:43 PM
Dates	Registration Date	Insert	New Registration		1/15/2020 3:43:26 PM	1/15/2020 3:43 PM
Dates	Signed By Date	Insert	New Registration			1/15/2020 3:43 PM
Dates	Start Date	Insert	New Registration			1/15/2020 3:43 PM
Terminations	Termination Comments	Insert	New Registration			1/15/2020 3:43 PM
Terminations	Termination Date	Insert	New Registration			1/15/2020 3:43 PM
Terminations	Termination Effective Date	Insert	New Registration			1/15/2020 3:43 PM
Terminations	Termination Reason	Insert	New Registration			1/15/2020 3:43 PM