Basic Information
Provider Information | |||||||||
NPI: | 1982029468 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REDINGTON-FAIRVIEW GENERAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SWING BED UNIT | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 04976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2074745121 | ||||||||
FaxNumber: | 2074749261 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2014 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOUCETTE | ||||||||
AuthorizedOfficialFirstName: | ELMER | ||||||||
AuthorizedOfficialMiddleName: | H. | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2078582176 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | REDINGTON-FAIRVIEW GENERAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 38550 | ME | N |   | Hospital Units | Medicare Defined Swing Bed Unit |   | 275N00000X | 38968 | ME | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
ID Information
ID | Type | State | Issuer | Description | 38968 | 01 | ME | DHHS - STATE OF MAINE | OTHER |