Healthcare Provider Details

I. General information

NPI: 1982633608
Provider Name (Legal Business Name): M. BROOKE HERNDON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 OLD ETNA RD DHMC. DEPARTMENT OF GENERAL INTERNAL MEDICINE
LEBANON NH
03766
US

IV. Provider business mailing address

1 MEDICAL CENTER DR DHMC. DEPARTMENT OF GENERAL INTERNAL MEDICINE
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-4000
  • Fax: 603-650-4190
Mailing address:
  • Phone: 603-650-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11316
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: