Basic Information
| Provider Information | |||||||||
| NPI: | 1548462096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE VASCULAR, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 CUMMINGS CTR | ||||||||
| Address2: | SUITE 118T | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782323555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 CUMMINGS CTR | ||||||||
| Address2: | SUITE 118T | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019156198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782323555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | DOOLEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9782323555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 152376 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9737936 | 05 | MA | MEDICAID |