1114175627 NPI number — VERNON INTEGRATIVE MEDICAL GROUP LLC

Table of content: (NPI 1114175627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114175627 NPI number — VERNON INTEGRATIVE MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERNON INTEGRATIVE MEDICAL GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114175627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 WINTHROP ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-754-9950
Provider Business Mailing Address Fax Number:
508-754-2592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 WINTHROP ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-754-9950
Provider Business Practice Location Address Fax Number:
508-754-2592
Provider Enumeration Date:
09/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TRISTER
Authorized Official First Name:
JON
Authorized Official Middle Name:
Authorized Official Title or Position:
MD INTERNAL MEDICINE
Authorized Official Telephone Number:
508-754-9950

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  80587 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0400664 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 43899 . This is a "BMCHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5841132 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1928586 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33586 . This is a "HEALTH NEW ENGLAND" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110082379A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 29736 . This is a "FALLON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6141990001 . This is a "NATIONAL SUPPLIER CLEARINGHOUSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J16290 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0400053 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 985162 . This is a "NETWORK HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3144941 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080587 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 66212 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".




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