MEDICARE: NORTHEAST NEUROSCIENCE, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	DC7828	OTHER		RR MCARE / PALMETTO GBA
3	1273X	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1689663064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST NEUROSCIENCE, PC

Provider Business Mailing Address
First Line	:	100 MEDICAL DR
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-3361
Country	:	US
Telephone Number	:	252-335-9900
Fax Number	:	252-335-9920

Provider Business Practice Location Address
First Line	:	100 MEDICAL DR
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-3361
Country	:	US
Telephone Number	:	252-335-9900
Fax Number	:	252-335-9920

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	VICTOR G. SONNINO
Credential	:	M.D.
Telephone Number	:	252-335-9900

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	08/22/2020

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