Provider Demographics
NPI:1386949808
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:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-622-4500
Mailing Address - Street 1:23 BOWDOIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04351
Mailing Address - Country:US
Mailing Address - Phone:207-629-5522
Mailing Address - Fax:207-512-8793
Practice Address - Street 1:23 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:207-629-5522
Practice Address - Fax:207-512-8793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0021056Medicare PIN