Basic Information
| Provider Information | |||||||||
| NPI: | 1770788044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ESINHART | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
| OtherMiddleName: | RAE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | DHMC, DEPARTMENT OF GENERAL INTERNAL MEDICINE | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036504000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18 OLD ETNA RD | ||||||||
| Address2: | DHMC, DEPARTMENT OF GENERAL INTERNAL MEDICINE | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036504000 | ||||||||
| FaxNumber: | 6036504190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 12/03/2012 | ||||||||
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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 | 207R00000X | 14959 | NH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1018052 | 05 | VT | MEDICAID | 30209834 | 05 | NH | MEDICAID |