Basic Information
Provider Information | |||||||||
NPI: | 1295805950 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALICE PECK DAY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EMERGENCY SERVICES AT ALICE PECK DAY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 ALICE PECK DAY DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037662647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034483121 | ||||||||
FaxNumber: | 6034487462 | ||||||||
Practice Location | |||||||||
Address1: | 10 ALICE PECK DAY DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037662647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034487448 | ||||||||
FaxNumber: | 6034439516 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2006 | ||||||||
LastUpdateDate: | 04/23/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOONEY | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6034483121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ALICE PECK DAY MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   | 282NC0060X | 00016 | NH | N |   | Hospitals | General Acute Care Hospital | Critical Access | 208D00000X | 00016 | NH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 30002661 | 05 | NH |   | MEDICAID | 0009582 | 05 | VT |   | MEDICAID |