Provider Demographics
NPI:1306843024
Name:BERUBE, RANDY G (PT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:G
Last Name:BERUBE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-2734
Mailing Address - Country:US
Mailing Address - Phone:603-625-1864
Mailing Address - Fax:603-668-7181
Practice Address - Street 1:700 LAKE AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-2734
Practice Address - Country:US
Practice Address - Phone:603-625-1864
Practice Address - Fax:603-668-7181
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1772225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30392139Medicaid
NH30392139Medicaid