Provider Demographics
NPI:1538248141
Name:SUNBURY PRIMARY CARE, P.A.
Entity type:Organization
Organization Name:SUNBURY PRIMARY CARE, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAVELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-942-7650
Mailing Address - Street 1:PO BOX 921
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0921
Mailing Address - Country:US
Mailing Address - Phone:207-990-0864
Mailing Address - Fax:207-990-5586
Practice Address - Street 1:900 BROADWAY
Practice Address - Street 2:BUILDING 1
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-1900
Practice Address - Country:US
Practice Address - Phone:207-945-2616
Practice Address - Fax:207-945-2623
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBURY PRIMARY CARE, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-03
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1028213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432023300Medicaid
ME=========021OtherHEALTHNET GROUP NUMBER
ME432023300Medicaid