Healthcare Provider Details

I. General information

NPI: 1679588339
Provider Name (Legal Business Name): KEITH D. JORGENSEN, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 BIRCH ST SUITE 304
DERRY NH
03038-2752
US

IV. Provider business mailing address

44 BIRCH ST SUITE 304
DERRY NH
03038-2752
US

V. Phone/Fax

Practice location:
  • Phone: 603-432-8104
  • Fax: 603-434-2629
Mailing address:
  • Phone: 603-432-8104
  • Fax: 603-434-2629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number7086
License Number StateNH

VIII. Authorized Official

Name: DR. KEITH D JORGENSEN
Title or Position: PRESIDENT
Credential: MD
Phone: 603-432-8104