Healthcare Provider Details

I. General information

NPI: 1700258779
Provider Name (Legal Business Name): PORTLAND COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BRICKHILL AVE
SOUTH PORTLAND ME
04106-1999
US

IV. Provider business mailing address

180 PARK AVE
PORTLAND ME
04102-2957
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. ANN TUCKER
Title or Position: CFO
Credential:
Phone: 207-874-2141