1457342735 NPI number — AVA R MOSKIN MD

Table of content: AVA R MOSKIN MD (NPI 1457342735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457342735 NPI number — AVA R MOSKIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSKIN
Provider First Name:
AVA
Provider Middle Name:
R
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:
1457342735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 LAKESIDE AVE STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-5906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-448-9719
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
443 CONGRESS ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04101-3531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-797-8881
Provider Business Practice Location Address Fax Number:
207-773-1697
Provider Enumeration Date:
11/04/2005

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:  015890 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060449 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 290170099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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