Provider Demographics
NPI:1811343890
Name:NE GASTRO LLC
Entity type:Organization
Organization Name:NE GASTRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:B
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-898-5082
Mailing Address - Street 1:17 HEARTHSTONE PL
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-5422
Mailing Address - Country:US
Mailing Address - Phone:603-898-5082
Mailing Address - Fax:603-890-5453
Practice Address - Street 1:52 STILES RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-4879
Practice Address - Country:US
Practice Address - Phone:603-898-5082
Practice Address - Fax:603-890-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207022207RG0100X
MA242931207RG0100X
NH9119207RG0100X
NH11071207RG0100X
NH16572207RG0100X
MA60421207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110072718AMedicaid
NH30214587Medicaid