Provider Demographics
NPI:1801892344
Name:SEACOAST AFFILIATED GROUP PRACTICE, INC.
Entity type:Organization
Organization Name:SEACOAST AFFILIATED GROUP PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-463-1010
Mailing Address - Street 1:25 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-3867
Mailing Address - Country:US
Mailing Address - Phone:978-463-1390
Mailing Address - Fax:978-463-1190
Practice Address - Street 1:25 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3867
Practice Address - Country:US
Practice Address - Phone:978-463-1390
Practice Address - Fax:978-463-1190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9785906Medicaid
MA9785906Medicaid