Basic Information
| Provider Information | |||||||||
| NPI: | 1629071899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUIR | ||||||||
| FirstName: | J GAVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 HOLLIS ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031011235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036269500 | ||||||||
| FaxNumber: | 6036260899 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HOLLIS ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031011235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036269500 | ||||||||
| FaxNumber: | 6036260899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 08/04/2008 | ||||||||
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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 | 207Q00000X | 10308 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30201968 | 05 | NH | MEDICAID |