Provider Demographics
NPI:1619151263
Name:NORTHEAST NEPHROLOGY & INTERNAL MEDICINE, PC
Entity Type:Organization
Organization Name:NORTHEAST NEPHROLOGY & INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DURGA
Authorized Official - Middle Name:E
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-689-2500
Mailing Address - Street 1:411 MERRIMACK ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-5821
Mailing Address - Country:US
Mailing Address - Phone:978-689-2500
Mailing Address - Fax:978-689-2502
Practice Address - Street 1:411 MERRIMACK ST
Practice Address - Street 2:SUITE 204
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-5821
Practice Address - Country:US
Practice Address - Phone:978-689-2500
Practice Address - Fax:978-689-2502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206923207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRAO30204898Medicaid
MA9790683Medicaid
MAM19469OtherBS OF MA
NHRAO30204898Medicaid
NH000396101Medicare PIN