Healthcare Provider Details

I. General information

NPI: 1992734164
Provider Name (Legal Business Name): PENOBSCOT COMMUNITY HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 COLDBROOK ROAD
HAMPDEN ME
04444-0000
US

IV. Provider business mailing address

1048 UNION ST SUITE 5
BANGOR ME
04401-8600
US

V. Phone/Fax

Practice location:
  • Phone: 207-862-2227
  • Fax: 207-862-2252
Mailing address:
  • Phone: 207-945-5247
  • Fax: 207-992-2154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN J KELLEY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 207-945-5247