1386715969 NPI number — DR. GERARD BLACKWOOD D.C.

Table of content: DR. GERARD BLACKWOOD D.C. (NPI 1386715969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386715969 NPI number — DR. GERARD BLACKWOOD D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKWOOD
Provider First Name:
GERARD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

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:
1386715969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1504 DORCHESTER AVE # B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DORCHESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02122-1327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-436-5454
Provider Business Mailing Address Fax Number:
617-436-5667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1504 DORCHESTER AVE # B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORCHESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02122-1327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-436-5454
Provider Business Practice Location Address Fax Number:
617-436-5667
Provider Enumeration Date:
11/13/2006

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: 111N00000X , with the licence number:  1561 , 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: 1613383 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA25980 . This is a "HARVARD PILGRIM PROVIDER#" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y39215 . This is a "BCBS OF MA PROVIDER NUMBE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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