Basic Information
| Provider Information | |||||||||
| NPI: | 1902907983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALAIS REGIONAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRH RADIOLOGY PHYSICIAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 24 HOSPITAL LN | ||||||||
| Address2: | |||||||||
| City: | CALAIS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074547521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCADAM | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2074547521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 101960403 | 05 | ME | MEDICAID |