MEDICARE: FULL CIRCLE HEALTH CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	DC9845	OTHER	ME	RAILROAD GRP #
3	3670329	OTHER	ME	AETNA GRP #

General Provider Information

NPI Number	:	1578521084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL CIRCLE HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	167 ACADEMY ST STE C
Second Line	:
City	:	PRESQUE ISLE
State	:	ME
Zip	:	04769-3167
Country	:	US
Telephone Number	:	207-764-7200
Fax Number	:	207-764-7204

Provider Business Practice Location Address
First Line	:	167 ACADEMY ST STE C
Second Line	:
City	:	PRESQUE ISLE
State	:	ME
Zip	:	04769-3167
Country	:	US
Telephone Number	:	207-764-7200
Fax Number	:	207-764-7204

Authorized Official
Title or Position	:	CEO
Name	:	E. VICTORIA GROVER
Credential	:	PA-C
Telephone Number	:	207-764-7200

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	05/11/2022

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Directions to “FULL CIRCLE HEALTH CARE LLC ” Practice Location

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