Provider Demographics
NPI:1205066222
Name:NORTHEASTERN UNIVERSITY
Entity type:Organization
Organization Name:NORTHEASTERN UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE AND TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-373-2597
Mailing Address - Street 1:30 LEON ST
Mailing Address - Street 2:503 BEHRAKIS HEALTH SCIENCES CENTER
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5009
Mailing Address - Country:US
Mailing Address - Phone:617-373-2492
Mailing Address - Fax:671-373-8756
Practice Address - Street 1:30 LEON ST
Practice Address - Street 2:503 BEHRAKIS HEALTH SCIENCES CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5009
Practice Address - Country:US
Practice Address - Phone:617-373-2492
Practice Address - Fax:671-373-8756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEASTERN UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-24
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4AKD235Z00000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA03276401OtherMEDICARE PTAN