Basic Information
| Provider Information | |||||||||
| NPI: | 1518928316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEMMETT | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035164265 | ||||||||
| FaxNumber: | 6037402713 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 OLD ROLLINSFORD RD | ||||||||
| Address2: | BUILDING B | ||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035164265 | ||||||||
| FaxNumber: | 6037402173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 12061 | NH | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 12061 | NH | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1518928316 | 05 | ME | MEDICAID | 3075234 | 05 | NH | MEDICAID |