Basic Information
| Provider Information | |||||||||
| NPI: | 1548344930 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STRAFFORD HEALTH ALLIANCE | ||||||||
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| OtherOrganizationName: | MARSH BROOK REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ROUTE 108 | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037427492 | ||||||||
| FaxNumber: | 6037426762 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 MARSH BROOK DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038786523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037496686 | ||||||||
| FaxNumber: | 6037503174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 06/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | QUINT | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6037496686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 140580101 | 05 | ME | MEDICAID | AA27346 | 01 | NH | HARVARD PILGRIM GROUP ID# | OTHER | 4923661 | 01 | NH | CIGNA GROUP ID# | OTHER |