Provider Demographics
NPI:1649345711
Name:NORTHEAST ENT
Entity type:Organization
Organization Name:NORTHEAST ENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNWALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-207-4462
Mailing Address - Street 1:299 FAUNCE CORNER RD
Mailing Address - Street 2:
Mailing Address - City:N. DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747
Mailing Address - Country:US
Mailing Address - Phone:508-995-0700
Mailing Address - Fax:508-995-3070
Practice Address - Street 1:299 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:N. DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747
Practice Address - Country:US
Practice Address - Phone:508-995-0700
Practice Address - Fax:508-995-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9773312Medicaid
MAM15900Medicare ID - Type Unspecified