Basic Information
| Provider Information | |||||||||
| NPI: | 1952482804 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DFD RUSSELL MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 CHURCH HILL RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LEEDS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042633418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075243501 | ||||||||
| FaxNumber: | 2075242459 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 CHURCH HILL RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | LEEDS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042633418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075243501 | ||||||||
| FaxNumber: | 2075242459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | KANE-LEWIS | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2075243501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | ME | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 168270000 | 05 | ME | MEDICAID |