Provider Demographics
NPI:1467565564
Name:PENOBSCOT BAY MEDICAL EQUIPMENT & SUPPLIES, INC.
Entity Type:Organization
Organization Name:PENOBSCOT BAY MEDICAL EQUIPMENT & SUPPLIES, INC.
Other - Org Name:PENOBSCOT BAY MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOWLTON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:207-236-3006
Mailing Address - Street 1:PO BOX 951
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04843-0951
Mailing Address - Country:US
Mailing Address - Phone:207-236-3006
Mailing Address - Fax:207-236-1018
Practice Address - Street 1:14 MILL ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:ME
Practice Address - Zip Code:04843-1510
Practice Address - Country:US
Practice Address - Phone:207-236-3006
Practice Address - Fax:207-236-1018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MENOT REQUIRED332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME115310000Medicaid
ME115310000Medicaid