Provider Demographics
NPI:1841475712
Name:PENOBSCOT COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:PENOBSCOT COMMUNITY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:
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:207-947-0435
Practice Address - Street 1:735 WILSON 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:207-989-1567
Practice Address - Fax:207-989-6889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENOBSCOT COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-09
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME131160200Medicaid
ME131160100Medicaid
ME131160100Medicaid