Basic Information
Provider Information | |||||||||
NPI: | 1285786061 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STRAFFORD HEALTH ALLIANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WOMEN'S LIFE IMAGING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 ROUTE 108 | ||||||||
Address2: | SUITE 3 | ||||||||
City: | SOMERSWORTH | ||||||||
State: | NH | ||||||||
PostalCode: | 038781119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037427492 | ||||||||
FaxNumber: | 6037426762 | ||||||||
Practice Location | |||||||||
Address1: | 200 ROUTE 108 | ||||||||
Address2: | SUITE 3 | ||||||||
City: | SOMERSWORTH | ||||||||
State: | NH | ||||||||
PostalCode: | 038781119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037427492 | ||||||||
FaxNumber: | 6037426762 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2007 | ||||||||
LastUpdateDate: | 01/08/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEAUDIN | ||||||||
AuthorizedOfficialFirstName: | BETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6037426673 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |   | 2471B0102X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Bone Densitometry | 2471M2300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Mammography | 261QR0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | 5733712 | 01 | NH | AETNA | OTHER | MNT924 | 01 | NH | HARVARD PILGRIM | OTHER | 30002834 | 05 | NH |   | MEDICAID | 7602818Y0NH01 | 01 | NH | ANTHEM | OTHER | 140580000 | 05 | ME |   | MEDICAID | 44411 | 01 | NH | CIGNA | OTHER | 155010 | 01 | NH | FDA CERTIFICATE # | OTHER |