MEDICARE: LONDONDERRY GASTROENTEROLOGY ASSOCIATES PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	6919	NH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851318281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONDONDERRY GASTROENTEROLOGY ASSOCIATES PA

Provider Business Mailing Address
First Line	:	1 COMMONS DR # B
Second Line	:	UNIT 9A
City	:	LONDONDERRY
State	:	NH
Zip	:	03053-3441
Country	:	US
Telephone Number	:	603-818-4712
Fax Number	:	603-421-6899

Provider Business Practice Location Address
First Line	:	1B COMMONS DR
Second Line	:	UNIT 9A
City	:	LONDONDERRY
State	:	NH
Zip	:	03053-3441
Country	:	US
Telephone Number	:	603-818-4712
Fax Number	:	603-421-6899

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. MARK KENNETH DETWEILER
Credential	:	M.D.
Telephone Number	:	603-818-4712

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	10/19/2015

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