Healthcare Provider Details

I. General information

NPI: 1255691556
Provider Name (Legal Business Name): NORTH SHORE PREVENTIVE HEALTH CARE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 HERRICK ST SUITE 116
BEVERLY MA
01915-5903
US

IV. Provider business mailing address

75 HERRICK ST SUITE 116
BEVERLY MA
01915-5903
US

V. Phone/Fax

Practice location:
  • Phone: 978-502-8850
  • Fax:
Mailing address:
  • Phone: 978-502-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45310
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number45310
License Number StateMA

VIII. Authorized Official

Name: DR. ROY LELAND RUFF
Title or Position: PRESIDENT
Credential: M.D.
Phone: 978-502-8850