Basic Information
| Provider Information | |||||||||
| NPI: | 1043373459 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST ORTHOPEDICS INC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 164 WETHERBY LN | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430814957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148392300 | ||||||||
| FaxNumber: | 6148392301 | ||||||||
| Practice Location | |||||||||
| Address1: | 164 WETHERBY LN | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430814957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148392300 | ||||||||
| FaxNumber: | 6148392301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 06/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | MERLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6148392300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2303064 | 05 | OH | MEDICAID | 5126128 | 01 | AETNA | OTHER |