| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 1012 Union St, Bangor, Maine |
| Authorized Official Name and Position | Lori L. Dwyer (CEO AND PRESIDENT) |
| Authorized Official Contact | 2074048200 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 1599 Bangor ME 04402-1599 Ph: (207) 945-5247 | 1012 Union St Bangor ME 04401 Ph: (207) 945-5247 |
| NPI Number | 1427169010 |
|---|---|
| Provider Enumeration Date | 08/31/2006 |
| Last Update Date | 08/06/2018 |
| Medicare PECOS PAC ID | 0143212670 |
|---|---|
| Medicare Enrollment ID | O20040402000293 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1427169010 | NPI | - | NPPES |
| 131160100 | Medicaid | ME | |
| 131160200 | Medicaid | ME |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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