NPIMap

Organization Active NPI

Penobscot Valley Dermatology, P.a.

  • Specialist
  • Bangor, ME
National Provider Identifier
1952536880
Registry record updated Jun 3, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
ME013153 Issued in ME
Legal business name
PENOBSCOT VALLEY DERMATOLOGY, P.A.
Practice address
90 Ridgewood Drive
Bangor, ME 04401-2652
Phone
(207) 942-0669
Fax
(207) 947-3143
NPI assigned
May 21, 2009
Last updated
Jun 3, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 3, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jeffrey Dean Pittis, MDNPI 1023006194
Title
Dermatologist
Phone
(207) 942-0669

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Specialist 174400000X ME013153 ME Primary

Addresses

Primary practice location

90 Ridgewood Drive
Bangor, ME 04401-2652

Mailing address

90 Ridgewood Drive
Bangor, ME 04401-2652
Phone (207) 942-0669

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090911000198 ME Part B Supplier - Clinic/Group Practice 7315092541 Receives reassigned benefits from 11 practitioners
Practice locations: Bangor, ME; Orono, ME

National Provider Directory

National Provider Directory

Locations

381 Main St
Orono, ME 04473
Phone (207) 942-0669

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1242864000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1243987200000",
    "number": "1952536880",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "90 RIDGEWOOD DRIVE",
            "city": "BANGOR",
            "state": "ME",
            "postal_code": "044012652",
            "telephone_number": "207-942-0669",
            "fax_number": "207-947-3143"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "90 RIDGEWOOD DRIVE",
            "city": "BANGOR",
            "state": "ME",
            "postal_code": "044012652",
            "telephone_number": "207-942-0669",
            "fax_number": "207-947-3143"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENOBSCOT VALLEY DERMATOLOGY, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-05-21",
        "last_updated": "2009-06-03",
        "status": "A",
        "authorized_official_last_name": "PITTIS",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "DEAN",
        "authorized_official_title_or_position": "DERMATOLOGIST",
        "authorized_official_telephone_number": "207-942-0669",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "ME",
            "license": "ME013153",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bangor, ME

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.