1740250620 NPI number — MRS. VIVIAN MAST PT

Table of content: MRS. VIVIAN MAST PT (NPI 1740250620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740250620 NPI number — MRS. VIVIAN MAST PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAST
Provider First Name:
VIVIAN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1740250620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3528 WADE AVENUE
Provider Second Line Business Mailing Address:
#139
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27607-4048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-782-5954
Provider Business Mailing Address Fax Number:
919-859-9444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2418 BLUE RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27607-6480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-782-5954
Provider Business Practice Location Address Fax Number:
919-859-9444
Provider Enumeration Date:
01/24/2006

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: 225100000X , with the licence number:  8793 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D9492 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5947795 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 130GC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".