Provider Demographics
NPI:1932137726
Name:NORTHEAST MEDICAL PRACTICE
Entity Type:Organization
Organization Name:NORTHEAST MEDICAL PRACTICE
Other - Org Name:CUMMINGS CENTER
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 1:107 CUMMINGS CTR
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6110
Practice Address - Country:US
Practice Address - Phone:978-927-1859
Practice Address - Fax:978-927-2388
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?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care