=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346242054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COOS COUNTY FAMILY HEALTH SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2005
-----------------------------------------------------
Last Update Date | 01/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 PLEASANT ST
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03570-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-752-2040
-----------------------------------------------------
Fax | 603-752-7797
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 PLEASANT ST
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03570-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-752-2040
-----------------------------------------------------
Fax | 603-752-7797
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | KENNETH GORDON
-----------------------------------------------------
Credential | CEO
-----------------------------------------------------
Telephone | 603-752-3669
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QF0050X
-----------------------------------------------------
Taxonomy Name | Non-Surgical Family Planning Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------