Healthcare Provider Details

I. General information

NPI: 1255845905
Provider Name (Legal Business Name): EXPRESSMED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 COLBY STREET
COLEBROOK NH
03576
US

IV. Provider business mailing address

700 LAKE AVE STE 2
MANCHESTER NH
03103
US

V. Phone/Fax

Practice location:
  • Phone: 603-331-0500
  • Fax:
Mailing address:
  • Phone: 603-782-8374
  • Fax: 603-782-5123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS VAILAS
Title or Position: MANAGING MEMBER
Credential:
Phone: 603-622-3670