Provider Demographics
NPI:1851558399
Name:GORHAM PRIMARY CARE PC
Entity Type:Organization
Organization Name:GORHAM PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT/INDIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-839-5551
Mailing Address - Street 1:130 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1319
Mailing Address - Country:US
Mailing Address - Phone:207-839-5551
Mailing Address - Fax:207-839-5573
Practice Address - Street 1:130 MAIN ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1319
Practice Address - Country:US
Practice Address - Phone:207-839-5551
Practice Address - Fax:207-839-5573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty