1043269582 NPI number — MS. LISA A MELLOW P.T.

Table of content: MS. LISA A MELLOW P.T. (NPI 1043269582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043269582 NPI number — MS. LISA A MELLOW P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELLOW
Provider First Name:
LISA
Provider Middle Name:
A
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1043269582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1524 ATWOOD AVE
Provider Second Line Business Mailing Address:
DBA/ROBERT BUONANNO
Provider Business Mailing Address City Name:
JOHNSTON
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02919-3228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-351-6200
Provider Business Mailing Address Fax Number:
401-351-6201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1524 ATWOOD AVE
Provider Second Line Business Practice Location Address:
DBA/ROBERT BUONANNO
Provider Business Practice Location Address City Name:
JOHNSTON
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02919-3228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-351-6200
Provider Business Practice Location Address Fax Number:
401-351-6201
Provider Enumeration Date:
05/10/2006

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:  PT00687 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7354 . This is a "BCBS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 204194/409026 . This is a "BLUECHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 1215115 . This is a "COVENTRY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: CD1829 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 050397249 . This is a "UNITEDHEALTHCARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 050397249 . This is a "PEQUOT PLUS HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0771230001 . This is a "DME REGION C" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 1043269582 . This is a "TUFTS HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12296688 . This is a "MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 050397249 . This is a "FIRST HLTH/COVENTRY/HCVM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 050397249 . This is a "WORKERS COMPENSATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0771230001 . This is a "DMEMAC REGION A" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 27673 . This is a "NEIGHBORHOOD HEALTH PLANS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: AA64883 . This is a "HARVARD HEALTH PLANS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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