Basic Information
Provider Information | |||||||||
NPI: | 1053353599 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH SHORE MAGNETIC IMAGING CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 68 PROSPECT ST | ||||||||
Address2: |   | ||||||||
City: | PEABODY | ||||||||
State: | MA | ||||||||
PostalCode: | 019601605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9785328960 | ||||||||
FaxNumber: | 9785320633 | ||||||||
Practice Location | |||||||||
Address1: | 68 PROSPECT ST | ||||||||
Address2: |   | ||||||||
City: | PEABODY | ||||||||
State: | MA | ||||||||
PostalCode: | 019601605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9785328960 | ||||||||
FaxNumber: | 9785320633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICHARDSON | ||||||||
AuthorizedOfficialFirstName: | ELEANOR | ||||||||
AuthorizedOfficialMiddleName: | NONE | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9785733116 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | 4385 | MA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
ID | Type | State | Issuer | Description | 29480 | 01 | MA | AETNA | OTHER | 018169 | 01 | MA | BC/BS OF MA | OTHER | 2226830784 | 01 | MA | CHAMPUS/TRICARE | OTHER | 605118 | 01 | MA | HARVARD PILGRIM | OTHER | 0007590 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 1530496 | 05 | MA |   | MEDICAID | 1600036 | 01 | MA | UNITED HEALTHCARE | OTHER | 709656 | 01 | MD | TUFTS HEALTH | OTHER | 31612 | 01 | MA | FALLON HEALTHCARE | OTHER |