Provider Demographics
NPI:1710175369
Name:NORTHEAST MEDICAL PRACITCE
Entity Type:Organization
Organization Name:NORTHEAST MEDICAL PRACITCE
Other - Org Name:INTERNAL MEDICINE OF THE NORTH SHORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF NMP
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-236-1710
Mailing Address - Street 1:140 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3629
Mailing Address - Country:US
Mailing Address - Phone:978-750-0200
Mailing Address - Fax:978-750-0220
Practice Address - Street 1:140 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3629
Practice Address - Country:US
Practice Address - Phone:978-750-0200
Practice Address - Fax:978-750-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19184OtherBC