Provider Demographics
NPI:1780799783
Name:DEBORAH A. CANNEY
Entity type:Organization
Organization Name:DEBORAH A. CANNEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PEDORTHIST
Authorized Official - Phone:763-607-6874
Mailing Address - Street 1:152 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:NH
Mailing Address - Zip Code:03833-2329
Mailing Address - Country:US
Mailing Address - Phone:603-580-2949
Mailing Address - Fax:267-350-9184
Practice Address - Street 1:152 FRONT ST
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:NH
Practice Address - Zip Code:03833-2329
Practice Address - Country:US
Practice Address - Phone:603-580-2949
Practice Address - Fax:267-350-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-08-07
Deactivation Date:2008-06-04
Deactivation Code:
Reactivation Date:2008-07-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30761514Medicaid
MA1540271Medicaid
705068OtherHARVARD PILGRIM HEALTH CA
705068OtherHARVARD PILGRIM HEALTH CA