Basic Information
| Provider Information | |||||||||
| NPI: | 1033117825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PISCATAQUA PLASTIC SURGERY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5087988012 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 BORTHWICK AVE | ||||||||
| Address2: | STE 206 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038014174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034315488 | ||||||||
| FaxNumber: | 6034314680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GAUDET | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6034315488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.