Basic Information
| Provider Information | |||||||||
| NPI: | 1275535999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOS COUNTY FAMILY HEALTH SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035702006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037527797 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | GORHAM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035811502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034662741 | ||||||||
| FaxNumber: | 6034662953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6037523669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | NH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | NH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 213E00000X | NH | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363AM0700X | NH | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LF0000X | NH | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 3007254 | 05 | NH | MEDICAID | 788438 | 01 | MVP HEALTHCARE | OTHER | CN7051 | 01 | MEDICARE RAILROAD | OTHER | 5830418 | 01 | AETNA | OTHER | 99908646 | 05 | NH | MEDICAID |