Provider Demographics
NPI:1689663064
Name:NORTHEAST NEUROSCIENCE, PC
Entity Type:Organization
Organization Name:NORTHEAST NEUROSCIENCE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:G
Authorized Official - Last Name:SONNINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-335-9900
Mailing Address - Street 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3361
Mailing Address - Country:US
Mailing Address - Phone:252-335-9900
Mailing Address - Fax:252-335-9920
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3361
Practice Address - Country:US
Practice Address - Phone:252-335-9900
Practice Address - Fax:252-335-9920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891273XMedicaid
DC7828OtherRR MCARE / PALMETTO GBA
NC1273XOtherBCBS
DC7828OtherRR MCARE / PALMETTO GBA
NC1273XOtherBCBS