Basic Information
| Provider Information | |||||||||
| NPI: | 1467436089 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOODWIN COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AVIS GOODWIN COMMUNITY HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 311 ROUTE 108 | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037492346 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 ROUTE 108 | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037492346 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 09/26/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ATKINS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6039560063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | NH | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 30011038 | 05 | NH | MEDICAID | 138790101 | 01 | ME | MAINECARE FFS | OTHER | 30312977 | 01 | NH | DENTAL MEDICAID | OTHER | 138790200 | 01 | ME | MAINE CARE | OTHER | 99909035 | 01 | ME | ME MEDICAID PRIMECARE | OTHER |