1326053786 NPI number — MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326053786 NPI number — MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.
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:
1326053786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 W CUMMINGS PARK
Provider Second Line Business Mailing Address:
SUITE 4700
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801-6372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-224-0661
Provider Business Mailing Address Fax Number:
781-224-1993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 W CUMMINGS PARK
Provider Second Line Business Practice Location Address:
SUITE 4700
Provider Business Practice Location Address City Name:
WOBURN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01801-6372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-224-0661
Provider Business Practice Location Address Fax Number:
781-224-1993
Provider Enumeration Date:
07/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TISSERA
Authorized Official First Name:
LALITH
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
781-224-0661

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  81635 , 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: 3143741 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007792 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M21864 . This is a "MEDICARE PIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: G10083 . This is a "MEDICARE UPIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 007792 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3143741 . This is a "MEDICAID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 776747 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M19048 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 222936 . This is a "PACIFICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: A20487 . This is a "MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J16485 . This is a "BLUECROSSBLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".