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General NPI Number Information
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NPI Number | 1124005590
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Entity Type | Organization
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Legal Business Name | NORTHEAST RETINA ASSOCIATES, PA
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Dates
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Enumeration Date | 12/28/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 272 COTTAGE ST
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City | SANFORD
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State | ME
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Zip | 04073-1815
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Country | US
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Telephone | 207-324-3380
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Fax | 207-636-5023
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Provider Business Mailing Address
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Address Line | 272 COTTAGE ST
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City | SANFORD
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State | ME
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Zip | 04073-1815
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Country | US
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Telephone | 207-324-3380
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Fax | 207-636-5023
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Authorized Official
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Title or Position | OPHTHALMIC MANAGER
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Name | JENNIFER BREAREY
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Credential |
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Telephone | 207-324-3380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 9375
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License Number State | NH
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 013866
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License Number State | ME
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