Provider Demographics
NPI:1437102456
Name:HUSE, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:HUSE
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 1:6 TSIENNETO RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-1584
Mailing Address - Country:US
Mailing Address - Phone:603-434-7444
Mailing Address - Fax:603-434-1733
Practice Address - Street 1:6 TSIENNETO RD
Practice Address - Street 2:SUITE 203
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1584
Practice Address - Country:US
Practice Address - Phone:603-434-7444
Practice Address - Fax:603-434-1733
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14586208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3082457Medicaid
NH3082457Medicaid
NHRAILROAD P00818043Medicare PIN
NH30209358Medicaid
NH001501901Medicare PIN
CT20000464Medicare PIN