Basic Information
| Provider Information | |||||||||
| NPI: | 1073590840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEB RADIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4238 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038024238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008894447 | ||||||||
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| Practice Location | |||||||||
| Address1: | 125 PARKER HILL AVE | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021202847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177546687 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | SPITZ | ||||||||
| AuthorizedOfficialFirstName: | DAMON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6172333035 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 9777482 | 05 | MA | MEDICAID |