1174600217 NPI number — SEACOAST FOOT SURGERY ASSOC

Table of content: (NPI 1174600217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174600217 NPI number — SEACOAST FOOT SURGERY ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEACOAST FOOT SURGERY ASSOC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174600217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 BORTHWICK AVENUE
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-430-8505
Provider Business Mailing Address Fax Number:
603-436-8381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 BORTHWICK AVENUE
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-430-8505
Provider Business Practice Location Address Fax Number:
603-436-8381
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAESIDE WILTON
Authorized Official First Name:
ROXANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
603-430-8505

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0183 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: POD212 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40368267 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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