Basic Information
| Provider Information | |||||||||
| NPI: | 1528719630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PORTLAND COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 PARK AVE | ||||||||
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| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078742141 | ||||||||
| FaxNumber: | 2077613738 | ||||||||
| Practice Location | |||||||||
| Address1: | 637 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041066425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078742141 | ||||||||
| FaxNumber: | 2077613738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2022 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | TUCKER | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2078742141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | AO | ||||||||
| NPICertificationDate: | 12/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.