Provider Demographics
NPI:1407385198
Name:WENTWORTH DOUGLASS HOSPITAL
Entity Type:Organization
Organization Name:WENTWORTH DOUGLASS HOSPITAL
Other - Org Name:DIABETES SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-740-3205
Mailing Address - Street 1:PO BOX 412540
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 OLD ROLLINSFORD RD STE 105
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2870
Practice Address - Country:US
Practice Address - Phone:603-742-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WENTWORTH DOUGLASS HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-07
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3074430Medicaid