1699180620 NPI number — NORTHEAST DERMATOLOGY ASSOCIATES, PC

Table of content: (NPI 1699180620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699180620 NPI number — NORTHEAST DERMATOLOGY ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST DERMATOLOGY ASSOCIATES, 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:
NEDA
Provider Other Organization Name Type Code:
5
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:
1699180620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 ANDOVER STREET
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
NORTH ANDOVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01845-5076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-691-5690
Provider Business Mailing Address Fax Number:
978-691-5693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 CONANT ST
Provider Second Line Business Practice Location Address:
FIRST FLOOR
Provider Business Practice Location Address City Name:
BEVERLY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01915-1665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-691-5690
Provider Business Practice Location Address Fax Number:
978-691-5693
Provider Enumeration Date:
06/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FINKLE
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-691-5690

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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