1164436812 NPI number — DR. MARY CATHERINE MANESIS-GILBERT DPM

Table of content: DR. MARY CATHERINE MANESIS-GILBERT DPM (NPI 1164436812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164436812 NPI number — DR. MARY CATHERINE MANESIS-GILBERT DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANESIS-GILBERT
Provider First Name:
MARY
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

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:
1164436812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
888 WORCESTER ST
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
WELLESLEY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02482-3744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-964-6681
Provider Business Mailing Address Fax Number:
339-686-2561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
888 WORCESTER ST
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
WELLESLEY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02482-3744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-964-6681
Provider Business Practice Location Address Fax Number:
339-686-2561
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  1956 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 0240 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 1713 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 171675501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30009080 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0357804 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00259202 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 480013145 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y70952 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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