Basic Information
| Provider Information | |||||||||
| NPI: | 1871755132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST HOSPITAL CORPORATION | ||||||||
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| 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: | MEDICAL STAFF OFFICE | ||||||||
| City: | BEVERLY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789223000 | ||||||||
| FaxNumber: | 9789217048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | CONROY | ||||||||
| AuthorizedOfficialFirstName: | DENIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9789223000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9709100 | 05 | MA | MEDICAID | M19581 | 01 | MA | BCBS MA | OTHER |