Provider Demographics
NPI:1124005590
Name:NORTHEAST RETINA ASSOCIATES, PA
Entity Type:Organization
Organization Name:NORTHEAST RETINA ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPHTHALMIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BREAREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-324-3380
Mailing Address - Street 1:272 COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-1815
Mailing Address - Country:US
Mailing Address - Phone:207-324-3380
Mailing Address - Fax:207-636-5023
Practice Address - Street 1:272 COTTAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-1815
Practice Address - Country:US
Practice Address - Phone:207-324-3380
Practice Address - Fax:207-636-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013866207W00000X
NH9375207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty