Provider Demographics
NPI:1043328685
Name:NORTHEAST HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:NORTHEAST HOSPITAL CORPORATION
Other - Org Name:CENTER FOR HEALTHY AGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CONROY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-922-3000
Mailing Address - Street 1:85 HERRICK STREET
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-922-3000
Mailing Address - Fax:978-921-7048
Practice Address - Street 1:480 MAPLE ST
Practice Address - Street 2:CENTER FOR HEALTHY AGING
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-4065
Practice Address - Country:US
Practice Address - Phone:866-479-3302
Practice Address - Fax:978-921-7048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACAP23308Medicare Oscar/Certification