Provider Demographics
NPI:1033117825
Name:PISCATAQUA PLASTIC SURGERY, PA
Entity Type:Organization
Organization Name:PISCATAQUA PLASTIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAUDET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-431-5488
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:STE 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-798-8012
Practice Address - Street 1:330 BORTHWICK AVE
Practice Address - Street 2:STE 206
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4174
Practice Address - Country:US
Practice Address - Phone:603-431-5488
Practice Address - Fax:603-431-4680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty