Basic Information
| Provider Information | |||||||||
| NPI: | 1710092804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUDHIR | ||||||||
| FirstName: | KENKERE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 LOUISE DR | ||||||||
| Address2: | |||||||||
| City: | HOLLIS | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030496008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038821501 | ||||||||
| FaxNumber: | 6038829747 | ||||||||
| Practice Location | |||||||||
| Address1: | 168 KINSLEY ST | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038821501 | ||||||||
| FaxNumber: | 6038829747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 6290 | NH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 80009584 | 05 | NH | MEDICAID |