Basic Information
| Provider Information | |||||||||
| NPI: | 1558314542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOLOGY ASSOCIATES OF THE NORTHEAST, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013020910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137728500 | ||||||||
| FaxNumber: | 4137728900 | ||||||||
| Practice Location | |||||||||
| Address1: | 745A ROUTE 63 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034433604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003038984 | ||||||||
| FaxNumber: | 6033634450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | CRESPO | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | LUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8003038984 | ||||||||
| 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 | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | OVN2029 | 05 | VT | MEDICAID | 30003577 | 05 | NH | MEDICAID | 8233 | 01 | VT | BC/BS | OTHER | 0104793Y0VT01 | 01 | NH | BC/BS | OTHER | 30212525 | 05 | NH | MEDICAID |