Provider Demographics
NPI:1801101993
Name:PENOBSCOT NATION HEALTH DEPARTMENT
Entity type:Organization
Organization Name:PENOBSCOT NATION HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERN DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:P
Authorized Official - Last Name:MACDOUGALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-817-7404
Mailing Address - Street 1:23 WABANAKI WAY
Mailing Address - Street 2:
Mailing Address - City:INDIAN ISLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04468-1252
Mailing Address - Country:US
Mailing Address - Phone:207-817-7400
Mailing Address - Fax:
Practice Address - Street 1:23 WABANAKI WAY
Practice Address - Street 2:
Practice Address - City:INDIAN ISLAND
Practice Address - State:ME
Practice Address - Zip Code:04468-1252
Practice Address - Country:US
Practice Address - Phone:207-817-7400
Practice Address - Fax:207-817-7459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011471A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center