1366454076 NPI number — RAJANI K MALLICK MD

Table of content: RAJANI K MALLICK MD (NPI 1366454076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366454076 NPI number — RAJANI K MALLICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLICK
Provider First Name:
RAJANI
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1366454076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14 TAUNTON AVE
Provider Second Line Business Mailing Address:
P O BOX BJ
Provider Business Mailing Address City Name:
NORTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02766-2707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-285-9500
Provider Business Mailing Address Fax Number:
508-285-3388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 TAUNTON AVE
Provider Second Line Business Practice Location Address:
P O BOX BJ
Provider Business Practice Location Address City Name:
NORTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02766-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-285-9500
Provider Business Practice Location Address Fax Number:
508-285-3388
Provider Enumeration Date:
08/12/2006

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: 207Q00000X , with the licence number:  RM086755 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 246529 , 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: 110088793A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA210168 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 764328 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J48474 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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