Provider Demographics
NPI:1164598090
Name:WALDO COUNTY GENERAL HOSPITAL
Entity Type:Organization
Organization Name:WALDO COUNTY GENERAL HOSPITAL
Other - Org Name:DONALD S. WALKER HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:TIBBETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-338-2500
Mailing Address - Street 1:43 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:ME
Mailing Address - Zip Code:04949
Mailing Address - Country:US
Mailing Address - Phone:207-589-4509
Mailing Address - Fax:207-589-3104
Practice Address - Street 1:43 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:ME
Practice Address - Zip Code:04949
Practice Address - Country:US
Practice Address - Phone:207-589-4509
Practice Address - Fax:207-589-3104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALDO COUNTY GENERAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36424261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME101570202Medicaid
ME101570202Medicaid
ME203984Medicare ID - Type Unspecified