Basic Information
| Provider Information | |||||||||
| NPI: | 1104873421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | APPLEDORE MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
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| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153725426 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26 MANCHESTER SQ | ||||||||
| Address2: | UNIT 1 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038012889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034312516 | ||||||||
| FaxNumber: | 6034319945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 11/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | CALKINS | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8042675950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30213400 | 05 | NH | MEDICAID | 142350004 | 05 | ME | MEDICAID |