Basic Information
Provider Information | |||||||||
NPI: | 1174549133 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REDINGTON-FAIRVIEW GENERAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 468 | ||||||||
Address2: |   | ||||||||
City: | SKOWHEGAN | ||||||||
State: | ME | ||||||||
PostalCode: | 049760468 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2074745121 | ||||||||
FaxNumber: | 2074749261 | ||||||||
Practice Location | |||||||||
Address1: | 46 FAIRVIEW AVE | ||||||||
Address2: |   | ||||||||
City: | SKOWHEGAN | ||||||||
State: | ME | ||||||||
PostalCode: | 049761481 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2074745121 | ||||||||
FaxNumber: | 2074749261 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOUCETTE | ||||||||
AuthorizedOfficialFirstName: | ELMER | ||||||||
AuthorizedOfficialMiddleName: | H. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2074745121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | 0645 | ME | N |   | Transportation Services | Ambulance | Land Transport | 282NC0060X | 38803 | ME | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 1174549133 | 05 | ME |   | MEDICAID |