Basic Information
| Provider Information | |||||||||
| NPI: | 1750625554 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUNDATION MEDICAL PARTNERS INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | IMMEDIATE CARE OF SOUTHERN NEW HAMPSHIRE-PELHAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3677 | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030613677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035777900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33 WINDHAM RD | ||||||||
| Address2: | |||||||||
| City: | PELHAM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030762372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035772273 | ||||||||
| FaxNumber: | 6036355441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2012 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6032818585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 03853 | NH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.