Basic Information
| Provider Information | |||||||||
| NPI: | 1164477568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY CLINICAL SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000 LBX 7660 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778202 | ||||||||
| FaxNumber: | 2077836660 | ||||||||
| Practice Location | |||||||||
| Address1: | 57 BIRCH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042407415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077535400 | ||||||||
| FaxNumber: | 2077860489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELIAS | ||||||||
| AuthorizedOfficialFirstName: | COLEEN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2075133897 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RG0300X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QF0400X | ME | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.