Provider Demographics
NPI:1649714742
Name:FULL CIRCLE DIRECT PRIMARY CARE
Entity type:Organization
Organization Name:FULL CIRCLE DIRECT PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINDA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-563-6616
Mailing Address - Street 1:68 CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4614
Mailing Address - Country:US
Mailing Address - Phone:207-563-6616
Mailing Address - Fax:207-563-6625
Practice Address - Street 1:68 CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4614
Practice Address - Country:US
Practice Address - Phone:207-563-6616
Practice Address - Fax:207-563-6625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD13738207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB6295OtherRAILROAD MEDICARE
MEME0255Medicare UPIN
ME185020000Medicaid