Provider Demographics
NPI:1851782312
Name:LONDONDERRY GASTROENTEROLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:LONDONDERRY GASTROENTEROLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:K
Authorized Official - Last Name:DETWEILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-744-9430
Mailing Address - Street 1:44 BIRCH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2752
Mailing Address - Country:US
Mailing Address - Phone:603-818-4714
Mailing Address - Fax:603-965-4063
Practice Address - Street 1:44 BIRCH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2752
Practice Address - Country:US
Practice Address - Phone:603-818-4712
Practice Address - Fax:603-965-4063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6919207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty