Provider Demographics
NPI:1538165642
Name:BLACK BEAR MEDICAL, INC.
Entity type:Organization
Organization Name:BLACK BEAR MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-441-8876
Mailing Address - Street 1:275 MARGINAL WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2542
Mailing Address - Country:US
Mailing Address - Phone:207-871-0008
Mailing Address - Fax:207-871-0590
Practice Address - Street 1:275 MARGINAL WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2542
Practice Address - Country:US
Practice Address - Phone:207-871-0008
Practice Address - Fax:207-871-0590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1019767332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME131150000Medicaid
ME128710000Medicaid