Provider Demographics
NPI:1710100839
Name:MAINE COAST MOBILE MED, LLC
Entity Type:Organization
Organization Name:MAINE COAST MOBILE MED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:FORST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-497-2996
Mailing Address - Street 1:PO BOX 1393
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1393
Mailing Address - Country:US
Mailing Address - Phone:207-460-8882
Mailing Address - Fax:207-907-4911
Practice Address - Street 1:1576 HAMMOND ST STE C
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5751
Practice Address - Country:US
Practice Address - Phone:207-404-4894
Practice Address - Fax:207-907-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERT3575247100000X
335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME684929OtherTUFTS
ME132120000Medicaid
MEMN3768OtherHARVARD PILGRIM
ME2328397OtherAETNA
MEM161680OtherCIGNA
ME630001645OtherRAILROAD MEDICARE
ME040509OtherBCBS
ME2328397OtherAETNA