Provider Demographics
NPI:1730187923
Name:NORTHERN NEW ENGLAND PRIMARY CARE
Entity type:Organization
Organization Name:NORTHERN NEW ENGLAND PRIMARY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-622-4500
Mailing Address - Street 1:29 BOWDOIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04351-3554
Mailing Address - Country:US
Mailing Address - Phone:207-622-4500
Mailing Address - Fax:207-622-5452
Practice Address - Street 1:29 BOWDOIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351
Practice Address - Country:US
Practice Address - Phone:207-622-4500
Practice Address - Fax:207-622-5452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 207LP2900X, 2086S0129X
ME204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1730187923Medicaid
ME134730000Medicaid