Healthcare Provider Details

I. General information

NPI: 1740373679
Provider Name (Legal Business Name): PENOBSCOT COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 DAVIS RD
BANGOR ME
04401
US

IV. Provider business mailing address

PO BOX 1599 103 MAINE AVE
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-2205
  • Fax: 207-992-2207
Mailing address:
  • Phone: 207-945-5247
  • Fax: 207-992-2154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: LORI L. DWYER
Title or Position: PRESIDENT & CEO
Credential: ESQ.
Phone: 207-992-9200