Provider Demographics
NPI:1174600217
Name:SEACOAST FOOT SURGERY ASSOC
Entity type:Organization
Organization Name:SEACOAST FOOT SURGERY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAESIDE WILTON
Authorized Official - Suffix:
Authorized Official - Credentials:CAPPM EFPM CPODCS
Authorized Official - Phone:603-430-8505
Mailing Address - Street 1:330 BORTHWICK AVENUE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801
Mailing Address - Country:US
Mailing Address - Phone:603-430-8505
Mailing Address - Fax:603-436-8381
Practice Address - Street 1:330 BORTHWICK AVENUE
Practice Address - Street 2:SUITE 112
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-430-8505
Practice Address - Fax:603-436-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD212213E00000X
NH0183213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH40368267Medicaid
NH40368267Medicaid
NH0662810001Medicare NSC
NHDH1698Medicare PIN
NHRE8638Medicare PIN