Healthcare Provider Details

I. General information

NPI: 1275535999
Provider Name (Legal Business Name): COOS COUNTY FAMILY HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BROADWAY AVE
GORHAM NH
03581-1502
US

IV. Provider business mailing address

133 PLEASANT ST
BERLIN NH
03570-2006
US

V. Phone/Fax

Practice location:
  • Phone: 603-466-2741
  • Fax: 603-466-2953
Mailing address:
  • Phone: 603-752-2040
  • Fax: 603-752-7797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNH
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNH
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNH
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNH
# 7
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: KENNETH GORDON
Title or Position: CEO
Credential:
Phone: 603-752-3669