Basic Information
| Provider Information | |||||||||
| NPI: | 1619940780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE EAR, NOSE & THROAT ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787456601 | ||||||||
| FaxNumber: | 9787444872 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787456601 | ||||||||
| FaxNumber: | 9787444872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEIDNER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9787456601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | C14552 | 01 | MA | RR MEDICARE GROUP NUMBER | OTHER | 34543 | 01 | MA | FALLON GROUP NUMBER | OTHER | M13205 | 01 | MA | BLUE SHIELD GROUP NUMBER | OTHER | 701493 | 01 | MD | TUFTS GROUP NUMBER | OTHER | 942871 | 01 | MA | AETNA GROUP NUMBER | OTHER | 9719032 | 05 | MA | MEDICAID |