Provider Demographics
NPI:1306822481
Name:SOUTHWORTH, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SOUTHWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WHITEHALL RD STE 205
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03867-3236
Mailing Address - Country:US
Mailing Address - Phone:603-994-6400
Mailing Address - Fax:603-335-6086
Practice Address - Street 1:6 HEALTHCARE DR STE 1
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-4499
Practice Address - Country:US
Practice Address - Phone:603-994-6400
Practice Address - Fax:603-994-6443
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0131602086S0129X
NH85392086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0123485OtherAETNA
020401332OtherMARTINS POINT
NH30004276Medicaid
008585OtherMAINE BLUE CROSS
NH3073850Medicaid
ME1306822481Medicaid
NHP00923460OtherRAILROAD MEDICARE
AA7682OtherHARVARD PILGRIM
ME299000099Medicaid
0105960Y0NH01OtherANTHEM BLUE CROSS
E77448Medicare UPIN
0123485OtherAETNA
NH3073850Medicaid
NH30004276Medicaid