Provider Demographics
NPI:1518082932
Name:ROBERT A. THERIAULT, D.O., PLLC
Entity Type:Organization
Organization Name:ROBERT A. THERIAULT, D.O., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:603-880-1511
Mailing Address - Street 1:190 BROAD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-3147
Mailing Address - Country:US
Mailing Address - Phone:603-578-9705
Mailing Address - Fax:
Practice Address - Street 1:190 BROAD ST STE 103
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-3147
Practice Address - Country:US
Practice Address - Phone:603-578-9705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE8262Medicare ID - Type Unspecified
NHF88284Medicare UPIN