1740304666 NPI number — LAURIE B. BOTIE, MD, PC

Table of content: (NPI 1740304666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740304666 NPI number — LAURIE B. BOTIE, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURIE B. BOTIE, MD, 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:
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:
1740304666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 CLARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEWKSBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01876-1699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-453-9272
Provider Business Mailing Address Fax Number:
978-970-1506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 CLARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEWKSBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01876-1699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-453-9272
Provider Business Practice Location Address Fax Number:
978-970-1506
Provider Enumeration Date:
03/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOTIE
Authorized Official First Name:
LAURIE
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-453-9272

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  46137 , 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: 01-00704 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 701208 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 7662 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9778489 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M16427 . This is a "BLUE CRS BL SHLD GROUP #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 6727439 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 56335 . This is a "AETNA GROUP #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 30002667 . This is a "MEDICAID NEW HAMPSHIRE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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