Provider Demographics
NPI:1568123594
Name:PENOBSCOT COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:PENOBSCOT COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORELLE
Authorized Official - Middle Name:
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:207-404-8200
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:885 BROADWAY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2961
Practice Address - Country:US
Practice Address - Phone:207-992-5500
Practice Address - Fax:207-990-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)