1700169711 NPI number — ELIZABETH BLACK SHORTSLEEVE NP-C

Table of content: ELIZABETH BLACK SHORTSLEEVE NP-C (NPI 1700169711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700169711 NPI number — ELIZABETH BLACK SHORTSLEEVE NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORTSLEEVE
Provider First Name:
ELIZABETH
Provider Middle Name:
BLACK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
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:
1700169711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
475 KILVERT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARWICK
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02886-1379
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-258-2551
Provider Business Mailing Address Fax Number:
855-643-5020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
279 NORTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02052-1211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-258-2551
Provider Business Practice Location Address Fax Number:
855-643-5020
Provider Enumeration Date:
09/26/2011

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: 363LF0000X , with the licence number:  NPP37637 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: RN2264330 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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