Basic Information
| Provider Information | |||||||||
| NPI: | 1639143852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAIDARUN | ||||||||
| FirstName: | SUSHELA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SONGTANIN | ||||||||
| OtherFirstName: | SUSHELA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | DHMC ENDOCRINOLOGY SECTION, DEPT OF MEDICINE | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036508630 | ||||||||
| FaxNumber: | 6036502240 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | DHMC ENDOCRINOLOGY SECTION, DEPT OF MEDICINE | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036508630 | ||||||||
| FaxNumber: | 6036502240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/11/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 14189 | NH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | P00053600 | 01 | WA | RAIL ROAD MEDICARE | OTHER | 299840 | 05 | OR | MEDICAID | 1015905 | 05 | VT | MEDICAID | 172221 | 01 | WA | L&I | OTHER | 8364564 | 05 | WA | MEDICAID | 30208311 | 05 | NH | MEDICAID |