Provider Demographics
NPI:1205377512
Name:PORTLAND COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:PORTLAND COMMUNITY HEALTH CENTER
Other - Org Name:PEAK ISLAND SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-753-7900
Mailing Address - Street 1:180 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2957
Mailing Address - Country:US
Mailing Address - Phone:207-874-2141
Mailing Address - Fax:
Practice Address - Street 1:4 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04108-3505
Practice Address - Country:US
Practice Address - Phone:207-874-2141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty