Provider Demographics
NPI:1841228632
Name:NORTHEAST PHYSICIAN PRACTICE
Entity Type:Organization
Organization Name:NORTHEAST PHYSICIAN PRACTICE
Other - Org Name:OB/GYN ASSOCIATES
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:978-818-6110
Mailing Address - Street 1:PO BOX 2149
Mailing Address - Street 2:NEMSO
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-5149
Mailing Address - Country:US
Mailing Address - Phone:978-818-6110
Mailing Address - Fax:978-818-6115
Practice Address - Street 1:225 BOSTON ST
Practice Address - Street 2:SUITE 205
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-3137
Practice Address - Country:US
Practice Address - Phone:781-595-4544
Practice Address - Fax:781-581-3740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty