MEDICARE: PISCATAQUA PLASTIC SURGERY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician		HI

General Provider Information

NPI Number	:	1033117825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PISCATAQUA PLASTIC SURGERY, PA

Provider Business Mailing Address
First Line	:	340 MAIN ST
Second Line	:	STE 670
City	:	WORCESTER
State	:	MA
Zip	:	01608-1604
Country	:	US
Telephone Number	:	508-754-3566
Fax Number	:	508-798-8012

Provider Business Practice Location Address
First Line	:	330 BORTHWICK AVE
Second Line	:	STE 206
City	:	PORTSMOUTH
State	:	NH
Zip	:	03801-4174
Country	:	US
Telephone Number	:	603-431-5488
Fax Number	:	603-431-4680

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES J GAUDET
Credential	:	M.D.
Telephone Number	:	603-431-5488

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/21/2022

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