Healthcare Provider Details

I. General information

NPI: 1043291727
Provider Name (Legal Business Name): GUS G. EMMICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CHAMBERS DR STE 2200
HOOKSETT NH
03106-1981
US

IV. Provider business mailing address

20 CHAMBERS DR STE 2200
HOOKSETT NH
03106-1981
US

V. Phone/Fax

Practice location:
  • Phone: 603-641-5386
  • Fax: 603-641-5387
Mailing address:
  • Phone: 603-641-5386
  • Fax: 603-641-5387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11270
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number285593
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11270
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: