Basic Information
Provider Information | |||||||||
NPI: | 1700218229 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ANDROSCOGGIN VALLEY HOSPITAL, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 59 PAGE HILL RD | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | NH | ||||||||
PostalCode: | 035703531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037522200 | ||||||||
FaxNumber: | 6037521836 | ||||||||
Practice Location | |||||||||
Address1: | 59 PAGE HILL RD | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | NH | ||||||||
PostalCode: | 035703531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037522200 | ||||||||
FaxNumber: | 6037521836 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2013 | ||||||||
LastUpdateDate: | 08/07/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORRIS | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 6033265639 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 00050 | NH | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 0449085 | 01 | NH | CIGNA | OTHER | 80300022 | 05 | NH |   | MEDICAID | 1GA | 01 | NH | ANTHEM | OTHER | 900452 | 01 | NH | HARVARD PILGRIM | OTHER |