=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992798482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENRY SCOTT BJERKE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2005
-----------------------------------------------------
Last Update Date | 05/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 ELLIOT WAY
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-627-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 PERRY RD
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03110-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-714-9685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 01051130A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 4301115212
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number | 01051130A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2086S0127X
-----------------------------------------------------
Taxonomy Name | Trauma Surgery Physician
-----------------------------------------------------
License Number | 2009018572
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2086S0127X
-----------------------------------------------------
Taxonomy Name | Trauma Surgery Physician
-----------------------------------------------------
License Number | 01051130A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2086S0127X
-----------------------------------------------------
Taxonomy Name | Trauma Surgery Physician
-----------------------------------------------------
License Number | 18055
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------