Provider Demographics
NPI:1386673952
Name:INDIAN STREAM HEALTH CENTER, INC
Entity Type:Organization
Organization Name:INDIAN STREAM HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-388-2426
Mailing Address - Street 1:141 CORLISS LANE
Mailing Address - Street 2:
Mailing Address - City:COLEBROOK
Mailing Address - State:NH
Mailing Address - Zip Code:03576
Mailing Address - Country:US
Mailing Address - Phone:603-237-8336
Mailing Address - Fax:603-237-4467
Practice Address - Street 1:141 CORLISS LANE
Practice Address - Street 2:
Practice Address - City:COLEBROOK
Practice Address - State:NH
Practice Address - Zip Code:03576
Practice Address - Country:US
Practice Address - Phone:603-237-8336
Practice Address - Fax:603-237-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH208D00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH7459647OtherAETNA
VT8000921Medicaid
NH200010975OtherMVP
NH30213617Medicaid
NH30513983Medicaid
NH8190651OtherCIGNA
VT00068661OtherBCBS OF VT
VT1011463Medicaid
NH303817Medicare ID - Type UnspecifiedRHC MEDICARE
VT1011463Medicaid
NH7459647OtherAETNA
NH30513983Medicaid
NHRE8542Medicare ID - Type UnspecifiedNHIC PART B
NH30513983Medicaid