Basic Information
| Provider Information | |||||||||
| NPI: | 1700258779 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTLAND COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH PORTLAND COMMUNITY HEALTH CENTER AT BRICK HILL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078742141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 BRICKHILL AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041061999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078742141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2015 | ||||||||
| LastUpdateDate: | 03/20/2017 | ||||||||
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| AuthorizedOfficialLastName: | TUCKER | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2078742141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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.