1730410192 NPI number — NORTHEAST SURGICAL SPECIALTIES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730410192 NPI number — NORTHEAST SURGICAL SPECIALTIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST SURGICAL SPECIALTIES, LLC
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:
6
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:
1730410192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5651 POPLAR TENT RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28027-7530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-403-7020
Provider Business Mailing Address Fax Number:
704-403-7039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5651 POPLAR TENT RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28027-7530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-403-7020
Provider Business Practice Location Address Fax Number:
704-403-7039
Provider Enumeration Date:
01/26/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAYMON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
F
Authorized Official Title or Position:
SR VP
Authorized Official Telephone Number:
704-403-2276

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5914068 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2342616 . This is a "MEDICARE PTAN, GROUP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DO1210 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".