=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366462616
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEACOAST ORTHOPEDIC ASSOC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 12/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 HIGHLAND AVE SUITE 16
-----------------------------------------------------
City | NEWBURYPORT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01950-3872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-462-7555
-----------------------------------------------------
Fax | 978-462-9049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 HIGHLAND AVE SUITE 16
-----------------------------------------------------
City | NEWBURYPORT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01950-3872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-462-7555
-----------------------------------------------------
Fax | 978-462-9049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. SANDRA GORDON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 978-462-7555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------