Provider Demographics
NPI:1518223437
Name:SEACOAST AFFILIATED GROUP PRACTICE
Entity Type:Organization
Organization Name:SEACOAST AFFILIATED GROUP PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-463-1010
Mailing Address - Street 1:25 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-3867
Mailing Address - Country:US
Mailing Address - Phone:978-463-1010
Mailing Address - Fax:978-463-1250
Practice Address - Street 1:25 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3867
Practice Address - Country:US
Practice Address - Phone:978-463-1010
Practice Address - Fax:978-463-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
M20862Medicare PIN