Basic Information
| Provider Information | |||||||||
| NPI: | 1225175763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDROSCOGGIN VALLEY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 59 PAGE HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035703542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 12TH ST | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035703860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 06/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | KEENE | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6033265601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANDROSCOGGIN VALLEY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 01499 | NH | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 30002625 | 05 | NH | MEDICAID |