Healthcare Provider Details

I. General information

NPI: 1104575166
Provider Name (Legal Business Name): NORTHEAST MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 VARNUM AVE STE 108
LOWELL MA
01854-2117
US

IV. Provider business mailing address

275 VARNUM AVE STE 108
LOWELL MA
01854-2117
US

V. Phone/Fax

Practice location:
  • Phone: 978-710-4242
  • Fax: 978-710-4202
Mailing address:
  • Phone: 978-710-4242
  • Fax: 978-710-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: SACHIN B PATEL
Title or Position: PRESIDENT
Credential: MD
Phone: 978-710-4242