Provider Demographics
NPI:1346242054
Name:COOS COUNTY FAMILY HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:COOS COUNTY FAMILY HEALTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:603-752-3669
Mailing Address - Street 1:133 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NH
Mailing Address - Zip Code:03570-2006
Mailing Address - Country:US
Mailing Address - Phone:603-752-2040
Mailing Address - Fax:603-752-7797
Practice Address - Street 1:133 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NH
Practice Address - Zip Code:03570-2006
Practice Address - Country:US
Practice Address - Phone:603-752-2040
Practice Address - Fax:603-752-7797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH133V00000X, 207Q00000X, 207R00000X, 207V00000X, 363A00000X, 363LP0200X, 363LW0102X
261QF0050X, 261QF0400X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-SurgicalGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN7051OtherMEDICARE RAILROAD
NH30007254Medicaid
NH99908646Medicaid
NHNH2315OtherMEDICARE B
CN7051OtherMEDICARE RAILROAD
NH99908646Medicaid
=========OtherFEDERAL TAX ID#
CN7051OtherMEDICARE RAILROAD