Basic Information
| Provider Information | |||||||||
| NPI: | 1134200702 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALAIS COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CALAIS COMMUNITY PROVIDER PRACTICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 43 PALMER ST | ||||||||
| Address2: | |||||||||
| City: | CALAIS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046191305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074548150 | ||||||||
| FaxNumber: | 2074540256 | ||||||||
| Practice Location | |||||||||
| Address1: | 37 PALMER ST | ||||||||
| Address2: | |||||||||
| City: | CALAIS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046191305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074548150 | ||||||||
| FaxNumber: | 2074540256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARR | ||||||||
| AuthorizedOfficialFirstName: | LYNNETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2072550269 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 208509 | ME | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 432126600 | 05 | ME | MEDICAID |