Basic Information
| Provider Information | |||||||||
| NPI: | 1407898760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SHORE PET IMAGING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019601605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785328960 | ||||||||
| FaxNumber: | 9785329163 | ||||||||
| Practice Location | |||||||||
| Address1: | 68 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019601605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785328960 | ||||||||
| FaxNumber: | 9785329163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | ELEANOR | ||||||||
| AuthorizedOfficialMiddleName: | NONE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9785733116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0208X | 4C5F | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mobile |
ID Information
| ID | Type | State | Issuer | Description | 039669 | 01 | MA | BC/BS OF MA | OTHER | 641402 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 0034316 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 3732728 | 01 | MA | AETNA | OTHER | AA20785 | 01 | MA | HARVARD PILGRIM HEALTH | OTHER |