Basic Information
Provider Information | |||||||||
NPI: | 1437707809 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONVENIENTMD LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 NH AVE STE 2 | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | NH | ||||||||
PostalCode: | 038012864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034106700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 77 DANIEL WEBSTER HWY | ||||||||
Address2: |   | ||||||||
City: | BELMONT | ||||||||
State: | NH | ||||||||
PostalCode: | 032203028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037370550 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2019 | ||||||||
LastUpdateDate: | 10/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DICKENS | ||||||||
AuthorizedOfficialFirstName: | GARETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE CHAIRMAN | ||||||||
AuthorizedOfficialTelephone: | 6035010863 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.