Basic Information
| Provider Information | |||||||||
| NPI: | 1922030493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERRY MEDICAL CENTER, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 TSIENNETO RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030381584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
| FaxNumber: | 6035371326 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 TSIENNETO RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030381584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035371300 | ||||||||
| FaxNumber: | 6035371326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6035371300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 83019373 | 05 | NH | MEDICAID | 709488 | 01 | NH | TUFTS | OTHER |