Healthcare Provider Details

I. General information

NPI: 1366558272
Provider Name (Legal Business Name): GRANITE STATE NEUROSURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 HAWTHORNE DR
BEDFORD NH
03110-6912
US

IV. Provider business mailing address

4 HAWTHORNE DR
BEDFORD NH
03110-6912
US

V. Phone/Fax

Practice location:
  • Phone: 603-472-8888
  • Fax: 603-472-9090
Mailing address:
  • Phone: 603-472-8888
  • Fax: 603-472-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANNE CHRISTINE TALBOT-KLEEMAN
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 603-472-8888