Provider Demographics
NPI:1336751825
Name:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Entity Type:Organization
Organization Name:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-742-5252
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MEMBERS WAY FL 5
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-5933
Practice Address - Country:US
Practice Address - Phone:603-609-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-18
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Multi-Specialty
No1835N1003XPharmacy Service ProvidersPharmacistNutrition SupportGroup - Multi-Specialty