Provider Demographics
NPI:1730323262
Name:H. D. GOODALL HOSPITAL INC.
Entity Type:Organization
Organization Name:H. D. GOODALL HOSPITAL INC.
Other - Org Name:PAVILION
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-324-4310
Mailing Address - Street 1:25 JUNE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-2621
Mailing Address - Country:US
Mailing Address - Phone:207-324-4310
Mailing Address - Fax:
Practice Address - Street 1:25 JUNE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2621
Practice Address - Country:US
Practice Address - Phone:207-324-4310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:H. D. GOODALL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2264311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME101480202Medicaid