Provider Demographics
NPI:1952536880
Name:PENOBSCOT VALLEY DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:PENOBSCOT VALLEY DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:PITTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-942-0669
Mailing Address - Street 1:90 RIDGEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2652
Mailing Address - Country:US
Mailing Address - Phone:207-942-0669
Mailing Address - Fax:207-947-3143
Practice Address - Street 1:90 RIDGEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2652
Practice Address - Country:US
Practice Address - Phone:207-942-0669
Practice Address - Fax:207-947-3143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME013153174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE98841Medicare UPIN