Basic Information
Provider Information | |||||||||
NPI: | 1871164681 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONVENIENTMD LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 NH AVE | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | NH | ||||||||
PostalCode: | 038012864 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034106700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 181 CAMBRIDGE ST | ||||||||
Address2: |   | ||||||||
City: | BURLINGTON | ||||||||
State: | MA | ||||||||
PostalCode: | 018032922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7817300045 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2021 | ||||||||
LastUpdateDate: | 07/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOISSONNEAULT | ||||||||
AuthorizedOfficialFirstName: | JAROD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE MGT | ||||||||
AuthorizedOfficialTelephone: | 6033196223 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.