Provider Demographics
NPI:1619940780
Name:NORTH SHORE EAR, NOSE & THROAT ASSOCIATES, PC
Entity Type:Organization
Organization Name:NORTH SHORE EAR, NOSE & THROAT ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEIDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-745-6601
Mailing Address - Street 1:55 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2100
Mailing Address - Country:US
Mailing Address - Phone:978-745-6601
Mailing Address - Fax:978-744-4872
Practice Address - Street 1:55 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2100
Practice Address - Country:US
Practice Address - Phone:978-745-6601
Practice Address - Fax:978-744-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAC14552OtherRR MEDICARE GROUP NUMBER
MA34543OtherFALLON GROUP NUMBER
MAM13205OtherBLUE SHIELD GROUP NUMBER
MD701493OtherTUFTS GROUP NUMBER
MA942871OtherAETNA GROUP NUMBER
MA9719032Medicaid
MAM13205OtherBLUE SHIELD GROUP NUMBER