Basic Information
| Provider Information | |||||||||
| NPI: | 1255426300 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHESHIRE MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | CRNA GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 580 COURT ST | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034311718 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 580 COURT ST | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034311718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033545454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | CARUSO | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6033545454 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHESHIRE MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3111352 | 05 | NH | MEDICAID |