1386777407 NPI number — ANTHONY J AVERSA MD

Table of content: (NPI 1386777407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386777407 NPI number — ANTHONY J AVERSA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY J AVERSA MD
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:
6
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:
1386777407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 LOUDON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03301-5605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-224-2251
Provider Business Mailing Address Fax Number:
603-228-7047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 LOUDON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03301-5605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-224-2251
Provider Business Practice Location Address Fax Number:
603-228-7047
Provider Enumeration Date:
03/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AVERSA
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
603-224-2251

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  6913 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0106867Y0NH01 . This is a "ANTHEM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 80006867 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA25248 . This is a "HARVARD PILGRIM HLTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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