Healthcare Provider Details

I. General information

NPI: 1164175717
Provider Name (Legal Business Name): NEAAI - MACIPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 ERDMAN WAY STE 101
LEOMINSTER MA
01453-1805
US

IV. Provider business mailing address

79 ERDMAN WAY STE 101
LEOMINSTER MA
01453-1805
US

V. Phone/Fax

Practice location:
  • Phone: 978-537-4805
  • Fax: 978-537-2185
Mailing address:
  • Phone: 978-537-4805
  • Fax: 978-537-2185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: JORDAN E SCOTT
Title or Position: PRESIDENT/PHYSICIAN
Credential: MD
Phone: 978-537-4805