Basic Information
| Provider Information | |||||||||
| NPI: | 1891834545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERRY IMAGING CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 TSIENNETO RD | ||||||||
| Address2: | SUITE 100L | ||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030381584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
| FaxNumber: | 6035371324 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 TSIENNETO RD | ||||||||
| Address2: | SUITE 100L | ||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030381584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
| FaxNumber: | 6035371324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | DALLON | ||||||||
| AuthorizedOfficialFirstName: | DORREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6035371337 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | NH1602 | 01 | NH | HARVARD | OTHER | 7128517 | 01 | NH | AETNA | OTHER | 76Y007482NH01 | 01 | NH | ANTHEM BCBS | OTHER | 9938751 | 01 | NH | CIGNA | OTHER |