Provider Demographics
NPI:1700805868
Name:PENOBSCOT VALLEY HOSPITAL
Entity Type:Organization
Organization Name:PENOBSCOT VALLEY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-794-7129
Mailing Address - Street 1:7 TRANSALPINE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-4222
Mailing Address - Country:US
Mailing Address - Phone:207-794-3321
Mailing Address - Fax:207-794-2120
Practice Address - Street 1:7 TRANSALPINE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-4222
Practice Address - Country:US
Practice Address - Phone:207-794-3321
Practice Address - Fax:207-794-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME37453275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9221OtherPIN
ME135270000Medicaid
ME20Z303Medicare ID - Type Unspecified