Healthcare Provider Details

I. General information

NPI: 1720510175
Provider Name (Legal Business Name): KSENIA SKOROHODOVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KSENIA SKOROKHODOVA

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 RIVERWAY PL
BEDFORD NH
03110-6745
US

IV. Provider business mailing address

703 RIVERWAY PL
BEDFORD NH
03110-6745
US

V. Phone/Fax

Practice location:
  • Phone: 603-627-1661
  • Fax: 603-669-6944
Mailing address:
  • Phone: 603-627-1661
  • Fax: 603-669-6944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number33106
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number315671
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: