Provider Demographics
NPI:1750319547
Name:NORTHEAST PHYSICIAN PRACTICE
Entity Type:Organization
Organization Name:NORTHEAST PHYSICIAN PRACTICE
Other - Org Name:LYNNFIELD PRIMARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-236-1713
Mailing Address - Street 1:PO BOX 7091
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-0091
Mailing Address - Country:US
Mailing Address - Phone:978-922-3568
Mailing Address - Fax:978-922-3267
Practice Address - Street 1:628 SALEM ST
Practice Address - Street 2:
Practice Address - City:LYNNFIELD
Practice Address - State:MA
Practice Address - Zip Code:01940-2340
Practice Address - Country:US
Practice Address - Phone:781-598-4424
Practice Address - Fax:781-598-0630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21089Medicare ID - Type Unspecified