Healthcare Provider Details

I. General information

NPI: 1336104025
Provider Name (Legal Business Name): CITY OF OLD TOWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BRUNSWICK ST
OLD TOWN ME
04468-1408
US

IV. Provider business mailing address

PO BOX 1810
WINDHAM ME
04062-1810
US

V. Phone/Fax

Practice location:
  • Phone: 207-827-3400
  • Fax:
Mailing address:
  • Phone: 207-892-0020
  • Fax: 207-893-0583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number505
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier590008031
Identifier TypeOTHER
Identifier StateME
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier001170
Identifier TypeOTHER
Identifier StateME
Identifier IssuerBLUE CROSS

VIII. Authorized Official

Name: STEVE O'MALLEY
Title or Position: CHIEF
Credential:
Phone: 207-827-3962