Provider Demographics
NPI:1588693790
Name:PENOBSCOT COMMUNITY HEALTH CARE
Entity type:Organization
Organization Name:PENOBSCOT COMMUNITY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-945-5247
Mailing Address - Street 1:1048 UNION ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-8600
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-992-2154
Practice Address - Street 1:1012 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3060
Practice Address - Country:US
Practice Address - Phone:207-945-5247
Practice Address - Fax:207-992-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME038672363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty