Basic Information
| Provider Information | |||||||||
| NPI: | 1407827710 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BEVERLY HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 85 HERRICK STREET | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789223000 | ||||||||
| FaxNumber: | 9789217048 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HERRICK STREET | ||||||||
| Address2: | |||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789223000 | ||||||||
| FaxNumber: | 9789217048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONROY | ||||||||
| AuthorizedOfficialFirstName: | DENIS | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9789223000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | N | Hospital Units | Psychiatric Unit | 273R00000X | 15 | MA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 1202626 | 05 | MA | MEDICAID | 2222003306 | 01 | MD | BC INDEM IP PSYCH | OTHER | 900082 | 01 | MA | TUFTS MCR HMO OUTPAT | OTHER | 901790 | 01 | MA | TUFTS IP PSYCH | OTHER | 1000039 | 05 | MA | MEDICAID | 2222003311 | 01 | MA | BC HMO/PHO PSYCH OP | OTHER | 2222003325 | 01 | MA | BC OUTPAT INDEM PSYCH | OTHER | 9343 | 01 | MA | AETNA HMO PSYCH | OTHER | BEV2222003311 | 01 | MA | HMO BLUE PSYCH OP | OTHER | 0007079 | 01 | MA | NHP PSYCH | OTHER | 1898639 | 05 | MA | MEDICAID | 2222003301 | 01 | MA | BC HMO/PHO PSYCH IP | OTHER | 900082 | 01 | MA | TUFTS OUTPAT PSYCH | OTHER | BEV2222003301 | 01 | MD | HMO BLUE PSYCH IP | OTHER | 901790 | 01 | MA | TUFTS MCR HMO INPAT | OTHER | S005394 | 01 | MD | CHAMPUS | OTHER | 903159 | 01 | MA | HARVARD PILGRIM PSYCH | OTHER |