Healthcare Provider Details

I. General information

NPI: 1356683981
Provider Name (Legal Business Name): PENOBSCOT COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 BELMONT AVE STE 3
BELFAST ME
04915-7530
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-338-6900
  • Fax: 207-338-4974
Mailing address:
  • Phone: 207-945-5247
  • Fax: 207-947-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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