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General NPI Number Information
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NPI Number | 1386860716
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Entity Type | Organization
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Legal Business Name | REVERFRONT MEDICAL GROUP, PC
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 07/30/2008
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Provider Practice Location Address
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Address Line | 322 W MAIN ST SUITE 133
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City | TILTON
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State | NH
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Zip | 03276-5017
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Country | US
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Telephone | 603-286-3800
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Fax |
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Provider Business Mailing Address
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Address Line | 322 W MAIN ST SUITE 133
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City | TILTON
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State | NH
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Zip | 03276-5017
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Country | US
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Telephone | 603-286-3800
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN MARIE HARE
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Credential | M.D.
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Telephone | 603-286-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 10967
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License Number State | NH
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0185862302
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License Number State | NH
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 11415
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License Number State | NH
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