Provider Demographics
NPI:1710504683
Name:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Entity Type:Organization
Organization Name:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Other - Org Name:THE DOORWAY AT WD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE OPERATIONS
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 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:617-726-3884
Mailing Address - Fax:
Practice Address - Street 1:798 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2520
Practice Address - Country:US
Practice Address - Phone:603-609-6690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-26
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3126909Medicaid
NH3138637Medicaid
NH3117235Medicaid