Healthcare Provider Details

I. General information

NPI: 1841690377
Provider Name (Legal Business Name): PENOBSCOT FAMILY FOOT AND ANKLE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 FRENCH ST
BANGOR ME
04401-5064
US

IV. Provider business mailing address

205 FRENCH ST
BANGOR ME
04401-5064
US

V. Phone/Fax

Practice location:
  • Phone: 207-945-5554
  • Fax: 207-945-5196
Mailing address:
  • Phone: 207-945-5554
  • Fax: 207-945-5196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD1032
License Number StateME

VIII. Authorized Official

Name: MS. DIANE MARIA DESANTIS
Title or Position: BILLING MANAGER
Credential:
Phone: 781-231-7026