1265692230 NPI number — MAI TAI NGUYEN, M.D.

Table of content: (NPI 1265692230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265692230 NPI number — MAI TAI NGUYEN, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAI TAI NGUYEN, M.D.
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:
1265692230
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
186 BEACON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01810-2813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-686-9152
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 MERRIMACK ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
METHUEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01844-5821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-686-9152
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
MAI
Authorized Official Middle Name:
TAI
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
978-686-9152

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  54685 , 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: J04744 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: J04744 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier . This identifiers is of the category "OTHER".