Provider Demographics
NPI:1275906893
Name:PENOBSCOT COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:PENOBSCOT COMMUNITY HEALTH CENTER
Other - Org Name:HELEN HUNT HEALTH CENTER DME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO & PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:207-992-9200
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:242 BRUNSWICK ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468
Practice Address - Country:US
Practice Address - Phone:207-827-6128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENOBSCOT COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-04
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME4717130003Medicare NSC