Provider Demographics
NPI:1558314542
Name:DERMATOLOGY ASSOCIATES OF THE NORTHEAST, PC
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF THE NORTHEAST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:CRESPO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-303-8984
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01302-0910
Mailing Address - Country:US
Mailing Address - Phone:413-772-8500
Mailing Address - Fax:413-772-8900
Practice Address - Street 1:745A ROUTE 63
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:NH
Practice Address - Zip Code:03443-3604
Practice Address - Country:US
Practice Address - Phone:800-303-8984
Practice Address - Fax:603-363-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2029Medicaid
NH30003577Medicaid
VT8233OtherBC/BS
NH0104793Y0VT01OtherBC/BS
NH30212525Medicaid
VTOVN2029Medicaid