Basic Information
| Provider Information | |||||||||
| NPI: | 1184698441 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHREACH COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MADISON AREA HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8 S MAIN ST | ||||||||
| Address2: | PO BOX 200 | ||||||||
| City: | MADISON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049504501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076963992 | ||||||||
| FaxNumber: | 2076965434 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049504501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076963992 | ||||||||
| FaxNumber: | 2076965434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 11/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COGGINS | ||||||||
| AuthorizedOfficialFirstName: | CONSTANCE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2078725610 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | E58728 | ME | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 137970104 | 05 | ME | MEDICAID |