Provider Demographics
NPI:1437359155
Name:MERRIMACK VALLEY ENDOSCOPY CENTER TDI
Entity Type:Organization
Organization Name:MERRIMACK VALLEY ENDOSCOPY CENTER TDI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-521-3235
Mailing Address - Street 1:1 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-6278
Mailing Address - Country:US
Mailing Address - Phone:978-521-3235
Mailing Address - Fax:978-521-3235
Practice Address - Street 1:1 PARKWAY
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6278
Practice Address - Country:US
Practice Address - Phone:978-521-3235
Practice Address - Fax:978-521-3236
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERRIMACK VALLEY ENDOSCOPY CENTER TDI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA040569OtherBLUE CROSS BLUE SHIELD OF