MEDICARE: PENOBSCOT COMMUNITY HEALTH CARE

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1992734164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENOBSCOT COMMUNITY HEALTH CARE

Provider Business Mailing Address
First Line	:	1048 UNION ST
Second Line	:	SUITE 5
City	:	BANGOR
State	:	ME
Zip	:	04401-8600
Country	:	US
Telephone Number	:	207-945-5247
Fax Number	:	207-992-2154

Provider Business Practice Location Address
First Line	:	177 COLDBROOK ROAD
Second Line	:
City	:	HAMPDEN
State	:	ME
Zip	:	04444-0000
Country	:	US
Telephone Number	:	207-862-2227
Fax Number	:	207-862-2252

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	KEVIN J KELLEY
Credential	:
Telephone Number	:	207-945-5247

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	08/22/2020

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Directions to “PENOBSCOT COMMUNITY HEALTH CARE ” Practice Location

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