Provider Demographics
NPI:1245510049
Name:NORTHEAST DERMATOLOGY ASSOCIATES
Entity type:Organization
Organization Name:NORTHEAST DERMATOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, NORTHEAST DERMATOLOGY AS
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:P
Authorized Official - Last Name:FINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-691-5690
Mailing Address - Street 1:401 ANDOVER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-5076
Mailing Address - Country:US
Mailing Address - Phone:978-691-5690
Mailing Address - Fax:978-691-5693
Practice Address - Street 1:1 WALLACE BASHAW WAY
Practice Address - Street 2:SUITE 1002
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3875
Practice Address - Country:US
Practice Address - Phone:978-691-5690
Practice Address - Fax:978-691-5693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST DERMATOLOGY ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM15432OtherMEDICARE PTAN