Provider Demographics
NPI:1871930834
Name:CATHOLIC MEDICAL CENTER
Entity type:Organization
Organization Name:CATHOLIC MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, LABORATORY SVCS
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENCAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-663-5362
Mailing Address - Street 1:100 MCGREGOR ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-3730
Mailing Address - Country:US
Mailing Address - Phone:603-663-5362
Mailing Address - Fax:
Practice Address - Street 1:100 MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3730
Practice Address - Country:US
Practice Address - Phone:603-663-5362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-31
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH30D0993032291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH300034Medicare PIN