Provider Demographics
NPI:1528377454
Name:DFD RUSSELL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:DFD RUSSELL MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KANE-LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-524-3501
Mailing Address - Street 1:180 CHURCH HILL RD
Mailing Address - Street 2:STE 1
Mailing Address - City:LEEDS
Mailing Address - State:ME
Mailing Address - Zip Code:04263-3418
Mailing Address - Country:US
Mailing Address - Phone:207-524-3501
Mailing Address - Fax:207-524-2459
Practice Address - Street 1:11 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04259-7035
Practice Address - Country:US
Practice Address - Phone:207-933-9646
Practice Address - Fax:207-933-9645
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DFD RUSSELL MEDICA CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-27
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME168270000Medicaid
ME201888Medicare Oscar/Certification