1558314542 NPI number — DERMATOLOGY ASSOCIATES OF THE NORTHEAST, PC

Table of content: (NPI 1558314542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558314542 NPI number — DERMATOLOGY ASSOCIATES OF THE NORTHEAST, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES OF THE NORTHEAST, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558314542
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 910
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01302-0910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-772-8500
Provider Business Mailing Address Fax Number:
413-772-8900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
745A ROUTE 63
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03443-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-303-8984
Provider Business Practice Location Address Fax Number:
603-363-4450
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRESPO
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-303-8984

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OVN2029 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30003577 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8233 . This is a "BC/BS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 0104793Y0VT01 . This is a "BC/BS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30212525 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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