Provider Demographics
NPI:1184955692
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:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORST
Authorized Official - Suffix:
Authorized Official - Credentials:RADIOGRAPHER
Authorized Official - Phone:207-460-8882
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:207-460-8882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERT3575247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME132120000Medicaid
ME132120000Medicaid