Provider Demographics
NPI:1689903007
Name:BERWICK FAMILY HEALTH CENTER LLC
Entity Type:Organization
Organization Name:BERWICK FAMILY HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:LIBENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-698-7900
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03901-0719
Mailing Address - Country:US
Mailing Address - Phone:207-698-7900
Mailing Address - Fax:207-698-7977
Practice Address - Street 1:36 ENDICOTT
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246
Practice Address - Country:US
Practice Address - Phone:603-366-7700
Practice Address - Fax:603-366-7775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME174580000Medicaid
NH30202194Medicaid
NH30202194Medicaid