Provider Demographics
NPI:1730235565
Name:NORTH SHORE GERIATRIC ASSOCIATES
Entity type:Organization
Organization Name:NORTH SHORE GERIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHAMPNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-469-0649
Mailing Address - Street 1:100 CUMMINGS CTR STE 232C
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6126
Mailing Address - Country:US
Mailing Address - Phone:978-998-6799
Mailing Address - Fax:978-998-6803
Practice Address - Street 1:75 BRIMBAL AVE
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6009
Practice Address - Country:US
Practice Address - Phone:978-469-0649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60080207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19173OtherBLUE SHIELD