Basic Information
| Provider Information | |||||||||
| NPI: | 1831246693 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DUMORE | ||||||||
| FirstName: | SUSAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 RYE ST | ||||||||
| Address2: | STE 125 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038016829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036102200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 RYE ST | ||||||||
| Address2: | STE 125 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038016829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036102200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0849 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 542065286 | 01 | NH | TAX IDENTIFICATION NUMBER | OTHER | 0808117Y0NH01 | 01 | NH | ANTHEM PROVIDER NUMBER | OTHER | 626470 | 01 | NH | HPHC PROVIDER NUMBER | OTHER |