=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235170549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-STATE HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 07/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 BOULDER POINT DRIVE SUITE 1
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-536-4000
-----------------------------------------------------
Fax | 603-536-4001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 BOULDER POINT DRIVE SUITE 1
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-536-4000
-----------------------------------------------------
Fax | 603-536-4001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ROBERT MACLEOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-536-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------