Provider Demographics
NPI:1851318281
Name:LONDONDERRY GASTROENTEROLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:LONDONDERRY GASTROENTEROLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:DETWEILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-818-4712
Mailing Address - Street 1:1 COMMONS DR # B
Mailing Address - Street 2:UNIT 9A
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3441
Mailing Address - Country:US
Mailing Address - Phone:603-818-4712
Mailing Address - Fax:603-421-6899
Practice Address - Street 1:1B COMMONS DR
Practice Address - Street 2:UNIT 9A
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3441
Practice Address - Country:US
Practice Address - Phone:603-818-4712
Practice Address - Fax:603-421-6899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80001279Medicaid
NH80001279Medicaid