1366541039 NPI number — CHRISTINE A MATTERA

Table of content: CHRISTINE A MATTERA (NPI 1366541039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366541039 NPI number — CHRISTINE A MATTERA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTERA
Provider First Name:
CHRISTINE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1366541039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
453 MOUNT PLEASANT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISVILLE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02830-1720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-765-7599
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 JOHN A CUMMINGS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOONSOCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02895-3247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-235-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2006

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: 101YA0400X , with the licence number:  LCDP00159 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YM0800X , with the licence number: MCH00140 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 407700 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: CM26347 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6252869 . This is a "UNITED HEALTH" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 0000030461 . This is a "BLUE CROSS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".