Provider Demographics
NPI:1447352430
Name:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Entity type:Organization
Organization Name:WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-643-5112
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:789 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-742-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 133V00000X, 207LP2900X, 207RC0000X, 207RE0101X, 207RG0300X, 207RH0003X, 207RI0200X, 207RP1001X, 207RR0500X, 207YX0007X, 208G00000X, 208M00000X, 2471M1202X
NH207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3123060Medicaid
NH3084198Medicaid
NH3081002Medicaid
NH3081002Medicaid