1568458479 NPI number — DR. GARY JOHN NIELAN

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568458479 NPI number — DR. GARY JOHN NIELAN

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

NIELAN

Provider First Name:

GARY

Provider Middle Name:

JOHN

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

M

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:

1568458479

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2207 BOSTON RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

WILBRAHAM

Provider Business Mailing Address State Name:

MA

Provider Business Mailing Address Postal Code:

01095-1155

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

413-599-1201

Provider Business Mailing Address Fax Number:

413-596-2940

Provider First Line Business Practice Location Address:

2207 BOSTON RD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

WILBRAHAM

Provider Business Practice Location Address State Name:

MA

Provider Business Practice Location Address Postal Code:

01095-1155

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

413-599-1201

Provider Business Practice Location Address Fax Number:

413-596-2940

Provider Enumeration Date:

09/26/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2080A0000X , with the licence number:  155058 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 2017078 . This is a "AETNA/USHC" identifier . This identifiers is of the category "OTHER".
• Identifier: 155058 . This is a "MA LICENSE" identifier . This identifiers is of the category "OTHER".
• Identifier: 23378 . This is a "HEALTH NEW ENGLAND" identifier . This identifiers is of the category "OTHER".
• Identifier: 28036 . This is a "CHILDRENS MEDICAL SECURIT" identifier . This identifiers is of the category "OTHER".
• Identifier: 353451 . This is a "HEALTHSOURCE MA NH" identifier . This identifiers is of the category "OTHER".
• Identifier: J18133 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
• Identifier: 102170 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 1550588404 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 3182916 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
• Identifier: 1204585 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 155058 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
• Identifier: 975887 . This is a "NETWORK HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 010155058MA01 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
• Identifier: 201928 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
• Identifier: 000000008141 . This is a "BOSTON MED CENTER HEALTH" identifier . This identifiers is of the category "OTHER".