1487885836 NPI number — DR. AMY DERIS MD

Table of content: DR. AMY DERIS MD (NPI 1487885836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487885836 NPI number — DR. AMY DERIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERIS
Provider First Name:
AMY
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
DAVEZAC
Provider Other First Name:
AMY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487885836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1493 CAMBRIDGE ST
Provider Second Line Business Mailing Address:
CHA MEDICAL STAFF OFFICE
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02139-1047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1493 CAMBRIDGE ST
Provider Second Line Business Practice Location Address:
CHA MEDICAL STAFF OFFICE
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02139-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-665-1616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2009

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:  A115114 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 257326 , 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)