1063446144 NPI number — MADELEINE MBUYAMBA M.D.

Table of content: MADELEINE MBUYAMBA M.D. (NPI 1063446144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063446144 NPI number — MADELEINE MBUYAMBA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MBUYAMBA
Provider First Name:
MADELEINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1063446144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
63 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROCKTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02301-4342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-559-1567
Provider Business Mailing Address Fax Number:
508-559-5073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
63 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-4012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-559-6699
Provider Business Practice Location Address Fax Number:
508-583-4649
Provider Enumeration Date:
07/11/2006

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: 208000000X , with the licence number:  159479 , 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: 32530 . This is a "HEALTHY START" identifier . This identifiers is of the category "OTHER".
  • Identifier: 98634901 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J25606 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0017976 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 32530 . This is a "CHILDRENS MEDICAL SEC. PL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000036884 . This is a "BMC HEALTHNET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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