Healthcare Provider Details

I. General information

NPI: 1225154065
Provider Name (Legal Business Name): MID-STATE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ROBIE ROAD
BRISTOL NH
03222-4506
US

IV. Provider business mailing address

101 BOULDER POINT DRIVE SUITE 1
PLYMOUTH NH
03264
US

V. Phone/Fax

Practice location:
  • Phone: 603-744-6200
  • Fax: 603-536-4001
Mailing address:
  • Phone: 603-536-4000
  • Fax: 603-536-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROBERT MACLEOD
Title or Position: CEO
Credential:
Phone: 603-536-4000