Basic Information
| Provider Information | |||||||||
| NPI: | 1316917941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST HOSPITAL CORPORATION | ||||||||
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| OtherOrganizationName: | NORTHEAST HOSPITAL CORPORATION | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 HERRICK ST | ||||||||
| Address2: | BEVERLY HOSPITAL | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019151776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789223000 | ||||||||
| FaxNumber: | 9789217071 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HERRICK ST | ||||||||
| Address2: | BEVERLY HOSPITAL | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019151776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789223000 | ||||||||
| FaxNumber: | 9789217071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | CORMIER | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9789223000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | V93D | MA | N | Hospital Units | Psychiatric Unit | 282N00000X | 15 | MA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1000039 | 05 | MA | MEDICAID | 2222003301 | 01 | MA | BC HMO/PHO INPAT | OTHER | 901790 | 01 | MA | TUFTS PHO INPAT | OTHER | 9343 | 01 | MA | AETNA HMO | OTHER | BEV2222003301 | 01 | MA | HMO BLUE INPAT | OTHER | S005394 | 01 | MA | CHAMPUS | OTHER | 2222003311 | 01 | MA | BC HMO/PHO OUTPAT | OTHER | 901790 | 01 | MA | TUFTS MCR INPAT | OTHER | 0007079 | 05 | MA | MEDICAID | 2222003301 | 01 | MA | BC INDEM INPAT | OTHER | 900385 | 01 | MA | FIRST SENIORITY | OTHER | 1202626 | 05 | MA | MEDICAID | 2222003311 | 01 | MA | BC INDEM OUTPAT | OTHER | 900082 | 01 | MA | TUFTS MCR OUTPAT | OTHER | 1000039 | 05 | MD | MEDICAID | 900082 | 01 | MA | TUFTS PHO OUTPAT | OTHER | 900385 | 01 | MA | HARVARD PILGRIM HMO | OTHER | BEV2222003311 | 01 | MA | HMO BLUE OUTPAT | OTHER |