Provider Demographics
NPI:1922281195
Name:BRIAN FRADETTE
Entity Type:Organization
Organization Name:BRIAN FRADETTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-537-1300
Mailing Address - Street 1:6 TSIENNETO RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-1584
Mailing Address - Country:US
Mailing Address - Phone:603-432-2508
Mailing Address - Fax:
Practice Address - Street 1:6 TSIENNETO RD
Practice Address - Street 2:SUITE 303
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-1584
Practice Address - Country:US
Practice Address - Phone:603-432-2508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0540820001Medicare NSC