Provider Demographics
NPI:1912003328
Name:EASTPORT MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:EASTPORT MEMORIAL HOSPITAL
Other - Org Name:EASTPORT MEMORIAL NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ERLEN
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-853-2531
Mailing Address - Street 1:23 BOYNTON STREET
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04628-1304
Mailing Address - Country:US
Mailing Address - Phone:207-853-2531
Mailing Address - Fax:207-853-7117
Practice Address - Street 1:23 BOYNTON STREET
Practice Address - Street 2:
Practice Address - City:EASTPORT
Practice Address - State:ME
Practice Address - Zip Code:04628-1304
Practice Address - Country:US
Practice Address - Phone:207-853-2531
Practice Address - Fax:207-853-7117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36544314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102120000Medicaid
ME205146Medicare Oscar/Certification