Provider Demographics
NPI:1922055094
Name:MERRIMACK VALLEY PET PC
Entity Type:Organization
Organization Name:MERRIMACK VALLEY PET PC
Other - Org Name:NEW ENGLAND PET IMAGING SYSTEM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-687-2321
Mailing Address - Street 1:354 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1754
Mailing Address - Country:US
Mailing Address - Phone:978-687-8187
Mailing Address - Fax:978-687-8185
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7121
Practice Address - Country:US
Practice Address - Phone:603-663-2370
Practice Address - Fax:603-663-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH446R261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
15Y002275MA02OtherBLUE CROSS OF NH
626241OtherHARVARD PILGRIM
685730OtherTUFTS
3184391OtherAETNA
NH30813476Medicaid
P00097739Medicare ID - Type UnspecifiedRAILROAD CARRIER
NH327081Medicare ID - Type Unspecified