Provider Demographics
NPI:1386777407
Name:ANTHONY J AVERSA MD
Entity type:Organization
Organization Name:ANTHONY J AVERSA MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:AVERSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-224-2251
Mailing Address - Street 1:111 LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5605
Mailing Address - Country:US
Mailing Address - Phone:603-224-2251
Mailing Address - Fax:603-228-7047
Practice Address - Street 1:111 LOUDON RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5605
Practice Address - Country:US
Practice Address - Phone:603-224-2251
Practice Address - Fax:603-228-7047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH6913207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0106867Y0NH01OtherANTHEM
NH80006867Medicaid
NHAA25248OtherHARVARD PILGRIM HLTHCARE
NH0106867Y0NH01OtherANTHEM
NHAA25248OtherHARVARD PILGRIM HLTHCARE