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General NPI Number Information
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NPI Number | 1851318281
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Entity Type | Organization
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Legal Business Name | LONDONDERRY GASTROENTEROLOGY ASSOCIATES PA
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 10/19/2015
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Provider Practice Location Address
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Address Line | 1B COMMONS DR UNIT 9A
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City | LONDONDERRY
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State | NH
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Zip | 03053-3441
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Country | US
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Telephone | 603-818-4712
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Fax | 603-421-6899
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Provider Business Mailing Address
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Address Line | 1 COMMONS DR # B UNIT 9A
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City | LONDONDERRY
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State | NH
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Zip | 03053-3441
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Country | US
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Telephone | 603-818-4712
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Fax | 603-421-6899
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MARK KENNETH DETWEILER
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Credential | M.D.
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Telephone | 603-818-4712
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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 | 6919
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License Number State | NH
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