Healthcare Provider Details

I. General information

NPI: 1386949808
Provider Name (Legal Business Name): NORTHERN NEW ENGLAND PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BOWDOIN ST
MANCHESTER ME
04351
US

IV. Provider business mailing address

23 BOWDOIN ST
MANCHESTER ME
04351
US

V. Phone/Fax

Practice location:
  • Phone: 207-629-5522
  • Fax: 207-512-8793
Mailing address:
  • Phone: 207-629-5522
  • Fax: 207-512-8793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS JORGENSEN
Title or Position: MANAGING MEMBER
Credential: DO
Phone: 207-622-4500