Provider Demographics
NPI:1902807431
Name:KING, RAYMOND T (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:T
Last Name:KING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:C/O ST MARY'S HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:077-778-6952
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:460 AMHERST ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-1255
Practice Address - Country:US
Practice Address - Phone:603-883-7970
Practice Address - Fax:603-595-3652
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2021-10-01
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
NH7747207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3079737Medicaid
NH3079737Medicaid
NX0393Medicare PIN