Provider Demographics
NPI:1841690377
Name:PENOBSCOT FAMILY FOOT AND ANKLE CENTER
Entity type:Organization
Organization Name:PENOBSCOT FAMILY FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:DESANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-231-7026
Mailing Address - Street 1:205 FRENCH ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5064
Mailing Address - Country:US
Mailing Address - Phone:207-945-5554
Mailing Address - Fax:207-945-5196
Practice Address - Street 1:205 FRENCH ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5064
Practice Address - Country:US
Practice Address - Phone:207-945-5554
Practice Address - Fax:207-945-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1032213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPENDINGMedicare PIN