Healthcare Provider Details

I. General information

NPI: 1659485423
Provider Name (Legal Business Name): GRANITE PHYSIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 COMMERCIAL ST STE 303
CONCORD NH
03301-5071
US

IV. Provider business mailing address

60 COMMERCIAL ST STE 303
CONCORD NH
03301-5096
US

V. Phone/Fax

Practice location:
  • Phone: 603-223-8145
  • Fax: 603-223-8146
Mailing address:
  • Phone: 603-223-8145
  • Fax: 603-223-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number9153
License Number StateNH

VIII. Authorized Official

Name: MR. STUART GLASSMAN
Title or Position: OWNER
Credential: MD
Phone: 603-223-8145