Healthcare Provider Details

I. General information

NPI: 1912610197
Provider Name (Legal Business Name): PORTLAND COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 RIVERSIDE ST
PORTLAND ME
04103
US

IV. Provider business mailing address

180 PARK AVE
PORTLAND ME
04102-2957
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-2141
  • Fax: 207-874-2164
Mailing address:
  • Phone: 207-874-2141
  • Fax: 207-761-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANN F TUCKER
Title or Position: CEO
Credential:
Phone: 207-874-2141