Basic Information
| Provider Information | |||||||||
| NPI: | 1104153535 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPEARE MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032641126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032382204 | ||||||||
| FaxNumber: | 6035362034 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 BOULDER POINT DRIVE | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032643168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035361284 | ||||||||
| FaxNumber: | 6035363136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCEWEN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6035361120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPEARE MEMORIAL HOSPITAL | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1017117 | 05 | VT | MEDICAID | 3076997 | 05 | NH | MEDICAID |