1356461891 NPI number — PHILIP C. IRVING,DDS,PC

Table of content: (NPI 1356461891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356461891 NPI number — PHILIP C. IRVING,DDS,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP C. IRVING,DDS,PC
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:
1356461891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1383 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01103-1653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-737-3700
Provider Business Mailing Address Fax Number:
413-736-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1383 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01103-1653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-737-3700
Provider Business Practice Location Address Fax Number:
413-736-6515
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IRVING
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
CRAIG
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
413-737-3700

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12970 , 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: 9713841 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0248509 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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