Basic Information
| Provider Information | |||||||||
| NPI: | 1205046992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOGAN | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 S MAIN ST STE H | ||||||||
| Address2: | |||||||||
| City: | WOLFEBORO | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038944411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035697690 | ||||||||
| FaxNumber: | 6035697664 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 S MAIN ST STE H | ||||||||
| Address2: | |||||||||
| City: | WOLFEBORO | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038944411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035697690 | ||||||||
| FaxNumber: | 6035697664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 14840 | NH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XP3100X | 4301083570 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207X00000X | ME103929 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000886300 | 05 | FL | MEDICAID | 9070299 | 01 | FL | AENTA | OTHER | 30366 | 01 | FL | BCBS | OTHER | 4131100 | 01 | FL | CIGNA | OTHER |