Provider Demographics
NPI:1629069323
Name:EMMICK, JASON G (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:G
Last Name:EMMICK
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 1:15 FREETOWN RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:NH
Mailing Address - Zip Code:03077-2358
Mailing Address - Country:US
Mailing Address - Phone:603-895-8000
Mailing Address - Fax:603-895-8099
Practice Address - Street 1:15 FREETOWN RD
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:NH
Practice Address - Zip Code:03077-2358
Practice Address - Country:US
Practice Address - Phone:603-895-8000
Practice Address - Fax:603-895-8099
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11692207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH01YP03984NH01OtherANTHEM ACES PIN
NH30203090Medicaid
NH0406992OtherUHC PIN
NH2943621OtherAETNA PIN
NH692880OtherHPHC PIN
NH011692OtherTUFTS PIN
NH20309YOtherANTHEM REFERRING RAN
NH110240392OtherRR MEDICARE PIN
NH3849838OtherCIGNA PIN
NH110240392OtherRR MEDICARE PIN
NH2943621OtherAETNA PIN