Basic Information
| Provider Information | |||||||||
| NPI: | 1881683415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | APPLEDORE MEDICAL GROUP II INC | ||||||||
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| OtherOrganizationName: | COASTAL CARDIOTHORACIC AND VASCULAR ASSOC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 BORTHWICK AVE | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038017128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035594111 | ||||||||
| FaxNumber: | 6035594110 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 BORTHWICK AVE | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038017128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035594111 | ||||||||
| FaxNumber: | 6035594110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8042377760 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 142350100 | 05 | ME | MEDICAID | 30212551 | 05 | NH | MEDICAID |