Healthcare Provider Details

I. General information

NPI: 1235450792
Provider Name (Legal Business Name): DMITRIY KEDRIN M.D. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 QUEEN CITY AVE ELLIOT GASTROENTEROLOGY
MANCHESTER NH
03101-7121
US

IV. Provider business mailing address

185 QUEEN CITY AVE ELLIOT GASTROENTEROLOGY
MANCHESTER NH
03101-7121
US

V. Phone/Fax

Practice location:
  • Phone: 603-314-6900
  • Fax:
Mailing address:
  • Phone: 603-314-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number17627
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: