Basic Information
| Provider Information | |||||||||
| NPI: | 1619951373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NATHAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SEYEDZADETH | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5 ALUMNI DR | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038332128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035806793 | ||||||||
| FaxNumber: | 6035807006 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 ALUMNI DR | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038332128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035806793 | ||||||||
| FaxNumber: | 6035807006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 10/28/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME91979 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 14892 | NH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01511 | 01 | FL | BCBS | OTHER | 1619951373 | 01 | NH | ANTHEM BCBS | OTHER | 110085918A | 05 | MA | MEDICAID | 271519800 | 05 | FL | MEDICAID | 30209704 | 05 | NH | MEDICAID | 435943599 | 05 | ME | MEDICAID | AA182828 | 01 | NH | HPHC | OTHER |