Provider Demographics
NPI:1922191857
Name:PENOBSCOT COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:PENOBSCOT COMMUNITY HEALTH CENTER
Other - Org Name:BREWER COMMUNITY SCHOOL BASED CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
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 2:103 MAINE AVE
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-992-2154
Practice Address - Street 1:92 PENDLETON ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412
Practice Address - Country:US
Practice Address - Phone:207-992-2393
Practice Address - Fax:207-992-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty