Basic Information
| Provider Information | |||||||||
| NPI: | 1427050012 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOS COUNTY FAMILY HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PLEASANT ST | ||||||||
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| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035702006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522040 | ||||||||
| FaxNumber: | 6037527797 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 PAGE HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035703531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522900 | ||||||||
| FaxNumber: | 6037523727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6037523669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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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 | 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 | 99908646 | 05 | NH | MEDICAID | 5830418 | 01 | AETNA GROUP | OTHER | 788438 | 01 | NH | MVP HEALTHCARE | OTHER | 30007254 | 05 | NV | MEDICAID |