MEDICARE: PORTLAND COMMUNITY HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1447694344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTLAND COMMUNITY HEALTH CENTER

Provider Business Mailing Address
First Line	:	180 PARK AVE
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04102-2957
Country	:	US
Telephone Number	:	207-874-2141
Fax Number	:

Provider Business Practice Location Address
First Line	:	59 RIVERTON DR
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-1050
Country	:	US
Telephone Number	:	207-874-2141
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MS. ANN TUCKER
Credential	:
Telephone Number	:	207-874-2141

Provider Enumeration Date	:	04/22/2013
Last Update Date	:	06/09/2023

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Directions to “PORTLAND COMMUNITY HEALTH CENTER ” Practice Location

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