1184782237 NPI number — DERMATOLOGY ASSOCIATES OF THE NORTHSHORE INC

Table of content: (NPI 1184782237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184782237 NPI number — DERMATOLOGY ASSOCIATES OF THE NORTHSHORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES OF THE NORTHSHORE 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:
1184782237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 ESSEX CENTER DR
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
PEABODY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01960-2910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-531-3736
Provider Business Mailing Address Fax Number:
978-538-3942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 ESSEX CENTER DR
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
PEABODY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01960-2910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-531-3736
Provider Business Practice Location Address Fax Number:
978-538-3942
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIMATTIA
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-531-3736

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  32419 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M12557 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2084291 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 707099 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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