Basic Information
Provider Information | |||||||||
NPI: | 1932133030 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUILL | ||||||||
FirstName: | MARSHALL | ||||||||
MiddleName: | ANDERSON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 MEDICAL CENTER DR | ||||||||
Address2: | DHMC DEPART OF MEDICINE/DERMATOLOGY | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037561000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036505000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 18 OLD ETNA RD | ||||||||
Address2: | DH DEPT OF DERMATOLOGY | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 03766 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036503100 | ||||||||
FaxNumber: | 6036503174 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 12/05/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | G16239 | GA | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207N00000X | 14454 | NH | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207NS0135X | GA16239 | GA | N |   | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207NS0135X | 14454 | NH | N |   | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
ID | Type | State | Issuer | Description | 30209308 | 05 | NH |   | MEDICAID | 070008491 | 01 | GA | RAILROAD MEDICARE | OTHER | 1017229 | 05 | VT |   | MEDICAID |