1053395491 NPI number — MERCEDES LEE CLINGERMAN PAC

Table of content: MERCEDES LEE CLINGERMAN PAC (NPI 1053395491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053395491 NPI number — MERCEDES LEE CLINGERMAN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLINGERMAN
Provider First Name:
MERCEDES
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLINGERMAN MURDOCK
Provider Other First Name:
MERCEDES
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053395491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 HALL DR
Provider Second Line Business Mailing Address:
VALLEY MEDICAL GROUP
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01002-2751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-256-8561
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 HALL DR
Provider Second Line Business Practice Location Address:
VALLEY MEDICAL GROUP
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01002-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-256-8561
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2005

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: 363AM0700X , with the licence number:  1588 , 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)