Speare Memorial Hospital
Organization Active NPI Rural Health Clinic/Center · Plymouth, NH
NPI 1326587635 · NPPES record last updated Sep 27, 2017
Key facts
- NPI
- 1326587635
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 01300 (NH)
- Legal business name
- SPEARE MEMORIAL HOSPITAL
- Practice address
- 71 Highland St
Plymouth, NH 03264-1233 - Phone
- (603) 536-3700
- Fax
- (603) 536-5384
- NPI assigned
- Feb 20, 2017
- Organization subpart
- No
Authorized official
- Name
- Michelle L. McEwen
- Title
- President / Ceo
- Phone
- (603) 536-1120
Owners & managing parties with NPI records 2
-
Joseph A Ebner, MD
Other NPIs on the same Medicare enrollment 6
Other NPIs with the same Medicare PAC ID 11
Related certifications (CCN) 4
Change of ownership 1
Practitioners 54
-
Fady E Abou Rizk, MD
-
Yaroslav Basyuk, MD
-
Reda Benhorma, MD
-
Adam M Boise, APRN
-
Eric M Bonnem, MD
-
Jamison Forrest Costello, D.O.
-
Joseph A Ebner, MD
-
Gregory J Englund, APRN
-
Vercin S Ephrem, MD
-
Kristina Marie Foss, FNP
-
Janette E Gaumer, R.D.
-
Gabrielle Elizabeth Gray, MSN, APRN, FNP-C
-
Jill H Hunter, APRN
-
David F Mattice, MD
-
Brittania McDonald, PA-C
-
Valentin Milchev, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 30D0883291 | Plymouth Pediatric & Adolescent Medicine | Certificate of waiver | Oct 22, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in NH
Rural health clinic certification: CCN 303995
- Legal name
- SPEARE MEMORIAL HOSPITAL
- Doing business as
- PLYMOUTH PEDIATRIC AND ADOLESCENT MEDICINE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Sep 29, 2025
- Last certification
- Jun 7, 2023
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Enrollment address
- 71 Highland St
Plymouth, NH 03264-1233 - Related CCNs
- 301311
All disclosed owners & managing parties 16
| Name | Role | Since | Share |
|---|---|---|---|
| Elizabeth Kleiner |
Corporate Director | Oct 31, 2019 | |
| Susan Scrimshaw |
Corporate Director | Oct 21, 2021 | |
| John Moulton |
Corporate Director |
Nov 1, 2024 | |
| Joseph T Caristi |
Corporate Officer |
Feb 19, 2024 | |
| Corporate Director |
Feb 19, 2024 | ||
| W-2 Managing Employee |
Feb 19, 2024 | ||
| Operational/Managerial Control |
Feb 19, 2024 | ||
| Margaret Turner |
Corporate Director |
Apr 9, 2017 | |
| Patrick B Miller |
Corporate Director |
Apr 9, 2017 | |
| Joseph a Ebner |
Corporate Director |
Jan 1, 2008 | |
| Kevin I Young |
Corporate Director |
Apr 9, 2017 | |
| Walter Johnson |
Corporate Director | Oct 25, 2018 | |
| Steven Camerino |
Corporate Director | Oct 23, 2019 | |
| Donna Driscoll |
Corporate Director |
Nov 1, 2024 | |
| Ken Evans |
Corporate Director |
Nov 1, 2024 | |
| Julie Bernier |
Corporate Director | Oct 25, 2018 | |
| Michelle L McEwen |
Corporate Officer |
Apr 9, 2017 | 100% |
| Corporate Director |
Apr 9, 2017 | 100% | |
| W-2 Managing Employee |
Apr 9, 2017 | 100% | |
| Operational/Managerial Control |
Apr 9, 2017 | 100% | |
| Eric M Shamansky |
Corporate Director |
Sep 11, 2023 | |
| W-2 Managing Employee |
Sep 11, 2023 | ||
| Operational/Managerial Control |
Sep 11, 2023 | ||
| Dolores C Hopper |
Corporate Director | Oct 27, 2022 |
Change-of-ownership history
| Date | Event | Counterparty |
|---|---|---|
| Apr 9, 2017 | Change of Ownership |
Dartmouth Hitchcock Clinic - Plymouth |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040823001172 | NH | Part B Supplier - Clinic/Group Practice | 1153318068 |
Receives reassigned benefits from 108 practitioners 6 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Bristol, NH; Meredith, NH; Plymouth, NH |
| O20170502000233 | NH | Part a Provider - Rural Health Clinic | 1153318068 | Practice locations: Plymouth, NH |
| O20210409001674 | NH | DME Supplier - Physician - General Practice | 1153318068 | Practice locations: Plymouth, NH |
National Provider Directory
Locations
71 Highland St
Plymouth, NH 03264
Phone (603) 536-3700
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 01300 | NH | Yes |
Addresses
Primary practice location
71 Highland St
Plymouth, NH 03264-1233
Mailing address
16 Hospital Rd
Plymouth, NH 03264-1126
Phone (603) 536-1120
Other names
- Plymouth Pediatric and Adolescent Medicine
Other providers in Plymouth, NH
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
- Speare Memorial Hospital
All providers in Plymouth, NH · Rural Health Clinic/Center in New Hampshire
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 27, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.