Basic Information
| Provider Information | |||||||||
| NPI: | 1740285501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FISKE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 253 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033017560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032262200 | ||||||||
| FaxNumber: | 8605233201 | ||||||||
| Practice Location | |||||||||
| Address1: | 253 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033017560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032262200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 03/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 039126 | CT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 30208122 | 05 | NH | MEDICAID |