Healthcare Provider Details

I. General information

NPI: 1558658757
Provider Name (Legal Business Name): GARY JAMES SWEET IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AYRES CIRCLE, BLDG. H-1, PNSY NAVAL BRANCH HEALTH CLINIC
PORTSMOUTH NH
03804
US

IV. Provider business mailing address

7 HOWARD ST
SPRINGVALE ME
04083-1920
US

V. Phone/Fax

Practice location:
  • Phone: 207-438-2450
  • Fax:
Mailing address:
  • Phone: 607-331-9683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: