1043364029 NPI number — TAESEON J ADAMS NP

Table of content: TAESEON J ADAMS NP (NPI 1043364029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043364029 NPI number — TAESEON J ADAMS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADAMS
Provider First Name:
TAESEON
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1043364029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 NEWPORT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02476-6207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-641-0495
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 SPRINGS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01730-1114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-687-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2007

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: 363LP0808X , with the licence number:  192447 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 192447 , 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: 0357375 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".