Healthcare Provider Details

I. General information

NPI: 1942309737
Provider Name (Legal Business Name): MOUSAM VALLEY PODIATRY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WHITEHALL RD SUITE #302
ROCHESTER NH
03867-3236
US

IV. Provider business mailing address

PO BOX 736
SPRINGVALE ME
04083-0736
US

V. Phone/Fax

Practice location:
  • Phone: 603-994-7633
  • Fax: 603-994-7648
Mailing address:
  • Phone: 603-994-7633
  • Fax: 603-994-7648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0193
License Number StateNH

VIII. Authorized Official

Name: SCOTT W GERRY
Title or Position: PRESIDENT/PODIATRIST
Credential: D.P.M.
Phone: 603-994-7633