MEDICARE: MOUSAM VALLEY PODIATRY, P.A.

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	213ES0103X	Foot & Ankle Surgery Podiatrist	0193	NH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1942309737	OTHER	ME	GROUP NPI #
2	1760487441	OTHER	ME	INDIVIDUAL NPI #
3	037709	OTHER	ME	ANTHEM
4	1942309737	OTHER	NH	NPI GROUP
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1760487441	OTHER	NH	INDIVIDUAL NPI
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942309737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUSAM VALLEY PODIATRY, P.A.

Provider Business Mailing Address
First Line	:	PO BOX 736
Second Line	:
City	:	SPRINGVALE
State	:	ME
Zip	:	04083-0736
Country	:	US
Telephone Number	:	603-994-7633
Fax Number	:	603-994-7648

Provider Business Practice Location Address
First Line	:	21 WHITEHALL RD
Second Line	:	SUITE #302
City	:	ROCHESTER
State	:	NH
Zip	:	03867-3236
Country	:	US
Telephone Number	:	603-994-7633
Fax Number	:	603-994-7648

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	10/21/2015

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Practice Location Address:

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1538258231 — DR. TIMOTHY MICHAEL SHERRY MD
Practice Location Address:

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Directions to “MOUSAM VALLEY PODIATRY, P.A. ” Practice Location

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