Provider Demographics
NPI:1336198175
Name:FOTHERGILL, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:FOTHERGILL
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 1:152 COLBY ST
Mailing Address - Street 2:
Mailing Address - City:COLEBROOK
Mailing Address - State:NH
Mailing Address - Zip Code:03576-3049
Mailing Address - Country:US
Mailing Address - Phone:603-331-0500
Mailing Address - Fax:603-237-8100
Practice Address - Street 1:152 COLBY ST
Practice Address - Street 2:
Practice Address - City:COLEBROOK
Practice Address - State:NH
Practice Address - Zip Code:03576-3049
Practice Address - Country:US
Practice Address - Phone:603-331-0500
Practice Address - Fax:603-237-8100
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHA66441OtherHARVARD PILGRIM
NH0105409YPNH02OtherBCBS OF NH
NHNH9636OtherNHIC PROVIDER #
NH1533376OtherCIGNA
VT1012501OtherVT MEDICAID
NH30002405Medicaid
VT00008076OtherBCBS OF VT
NH11819OtherMVP
NH5225563OtherAETNA
VT8001191OtherLADIES FIRST
NH301819Medicare ID - Type UnspecifiedFQHC PROVIDER NUBMER
NHNH9636OtherNHIC PROVIDER #