Basic Information
| Provider Information | |||||||||
| NPI: | 1376738096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMMONOOSUC COMMUNITY HEALTH SERVICES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MOUNT EUSTIS RD | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035613712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034442464 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 RAILROAD ST | ||||||||
| Address2: | |||||||||
| City: | WOODSVILLE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037851118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037473990 | ||||||||
| FaxNumber: | 6034443441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 03/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | SHANSHALA II | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6034442464 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMMONOOSUC COMMUNITY HEALTH SERVICES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | NH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QF0400X | NH | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 207Q00000X | NH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80301805 | 05 | NH | MEDICAID |