Provider Demographics
NPI:1336437128
Name:NORTHEAST UROLOGIC SURGERY, P.C.
Entity Type:Organization
Organization Name:NORTHEAST UROLOGIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PREVITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-686-3877
Mailing Address - Street 1:231 SUTTON ST
Mailing Address - Street 2:STE 1D
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-1620
Mailing Address - Country:US
Mailing Address - Phone:978-686-3877
Mailing Address - Fax:978-686-9586
Practice Address - Street 1:231 SUTTON ST
Practice Address - Street 2:STE 1D
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-1620
Practice Address - Country:US
Practice Address - Phone:978-686-3877
Practice Address - Fax:978-686-9586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9719911Medicaid
MAM12943OtherBLUE CROSS BLUE SHIELD MA
NH99904764Medicaid
MAM12943Medicare PIN
MA9719911Medicaid