Provider Demographics
NPI:1801566336
Name:NORTHEAST INSTITUTE FOR AGE MANAGEMENT
Entity type:Organization
Organization Name:NORTHEAST INSTITUTE FOR AGE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:COVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-232-7037
Mailing Address - Street 1:401 NEW RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 NEW RD STE 103
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1200
Practice Address - Country:US
Practice Address - Phone:609-232-7037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty