Basic Information
| Provider Information | |||||||||
| NPI: | 1477038461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WENTWORTH DOUGLASS HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 412540 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022412540 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 CORPORATE DR BLDG A | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038016895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037428787 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2018 | ||||||||
| LastUpdateDate: | 07/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | GAGNON | ||||||||
| AuthorizedOfficialFirstName: | TRISHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIR. OF REVENUE CYCLE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6037403205 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WENTWORTH DOUGLASS HOSPITAL | ||||||||
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| NPICertificationDate: | 07/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3074430 | 05 | NH | MEDICAID |