1588852768 NPI number — DAVID EAGAN PC

Table of content: (NPI 1588852768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588852768 NPI number — DAVID EAGAN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID EAGAN PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BROADWAY CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1588852768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 BOSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01904-2540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-599-8826
Provider Business Mailing Address Fax Number:
781-596-2156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 BOSTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01904-2540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-599-8826
Provider Business Practice Location Address Fax Number:
781-596-2156
Provider Enumeration Date:
10/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EAGAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
BOYD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
781-599-8826

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2527 , 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: 467545 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2453050 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 6399335 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA34472 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 661194 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y36758 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".