1811343890 NPI number — NE GASTRO 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 1811343890 NPI number — NE GASTRO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NE GASTRO 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:
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:
1811343890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 HEARTHSTONE PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01810-5422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-898-5082
Provider Business Mailing Address Fax Number:
603-890-5453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
52 STILES RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03079-4879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-898-5082
Provider Business Practice Location Address Fax Number:
603-890-5453
Provider Enumeration Date:
05/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
MAURICE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
603-898-5082

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  60421 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 207022 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 242931 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 9119 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 11071 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 16572 , 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: 110072718A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30214587 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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