1104163070 NPI number — ATLANTIC INTERNAL MEDICINE & PEDIATRICS, INC

Table of content: (NPI 1104163070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104163070 NPI number — ATLANTIC INTERNAL MEDICINE & PEDIATRICS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTIC INTERNAL MEDICINE & PEDIATRICS, INC
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:
1104163070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 GRIFFIN RD STE 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03801-7145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-373-0096
Provider Business Mailing Address Fax Number:
888-753-6169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 GRIFFIN RD STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03801-7145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-373-0096
Provider Business Practice Location Address Fax Number:
888-753-6169
Provider Enumeration Date:
01/11/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KURISH
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
603-373-0096

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  15882 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 15882 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3086915 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".