Provider Demographics
NPI:1922199348
Name:NORTHEAST GASTROENTEROLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:NORTHEAST GASTROENTEROLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAILAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-232-4513
Mailing Address - Street 1:55 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-1603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 MANOR PKWY STE 5
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-4871
Practice Address - Country:US
Practice Address - Phone:603-898-5082
Practice Address - Fax:603-890-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60421207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA697398OtherTUFTS GROUP NUMBER
MA9784594Medicaid
MA697398OtherTUFTS GROUP NUMBER
MA697398OtherTUFTS GROUP NUMBER
NH=========OtherANTHEM GROUP NUMBER