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NPI Code Detail

MEDICARE: NORTHEAST PHO, INC

MEDICARE: NORTHEAST PHO, INC
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
1171M00000XCase Manager/Care Coordinator

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1609238OTHERMATUFTS HEALTH PLAN
2M19283OTHERMABLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1952504706
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTHEAST PHO, INC
Provider Business Mailing Address
First Line : 55 TOZER RD
Second Line :
City : BEVERLY
State : MA
Zip : 01915-5515
Country : US
Telephone Number : 978-236-1744
Fax Number : 978-236-1777
Provider Business Practice Location Address
First Line : 55 TOZER RD
Second Line :
City : BEVERLY
State : MA
Zip : 01915-5515
Country : US
Telephone Number : 978-236-1744
Fax Number : 978-236-1777
Authorized Official
Title or Position : PRESIDENT
Name : DR. GREGORY BAZYLEWICZ
Credential : M.D.
Telephone Number : 978-236-1744
Provider Enumeration Date : 06/08/2007
Last Update Date : 08/22/2020

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Directions to “NORTHEAST PHO, INC ” Practice Location

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