Healthcare Provider Details

I. General information

NPI: 1750459244
Provider Name (Legal Business Name): ROBERT JERROLD RACUSIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR DHMC, DEPARTMENT OF PSYCHIATRY
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR DHMC, DEPARTMENT OF PSYCHIATRY
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5835
  • Fax: 603-650-0819
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5075
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number5465
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: