Provider Demographics
NPI:1679588339
Name:KEITH D. JORGENSEN, MD, PA
Entity type:Organization
Organization Name:KEITH D. JORGENSEN, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-432-8104
Mailing Address - Street 1:44 BIRCH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2752
Mailing Address - Country:US
Mailing Address - Phone:603-432-8104
Mailing Address - Fax:603-434-2629
Practice Address - Street 1:44 BIRCH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2752
Practice Address - Country:US
Practice Address - Phone:603-432-8104
Practice Address - Fax:603-434-2629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7086207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30001523Medicaid
NH30001523Medicaid
1258480001Medicare NSC