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DSH200063AP PENOBSCOT BAY MEDICAL CENTER (Terminated)
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Main Details
Name
PENOBSCOT BAY MEDICAL CENTER
Subdivision Name
PBPA PAIN MANAGEMENT AND PHYSICAL MEDICINE - Physical Medicine & Interventional Pain Management
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH200063AP
Medicare Provider Number
200063
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/3/2022
Participating Start Date
1/1/2023
Participating Approval Date
10/4/2022
Last Recertification Date
8/29/2023
Termination Date
Termination Reason
10/1/2024
Site closure
Contacts
Authorizing Official
Coastal Healthcare Alliance
Heather Shanklin, Chief Financial Officer
(207) 505-4131
Primary Contact
Coastal Health Alliance, MaineHealth
David MacMillan, Pharmacy Director
(207) 301-8563
Addresses
Street Address
4 Glen Cove Dr
Suite 206
Rockport, ME 04856
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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