Provider Demographics
NPI:1861451809
Name:PERENCEVICH, NICK P (MD)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:P
Last Name:PERENCEVICH
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 1:246 PLEASANT ST
Mailing Address - Street 2:MEMORIAL BUILDING SUITE 205
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2548
Mailing Address - Country:US
Mailing Address - Phone:603-224-0284
Mailing Address - Fax:603-225-5769
Practice Address - Street 1:246 PLEASANT ST
Practice Address - Street 2:MEMORIAL BUILDING SUITE 205
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2548
Practice Address - Country:US
Practice Address - Phone:603-224-0284
Practice Address - Fax:603-225-5769
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6677208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH00000580Medicaid
NHRE0395Medicare ID - Type Unspecified
NH00000580Medicaid