1063508893 NPI number — AFTHALIA KOUSTAS MSPT

Table of content: AFTHALIA KOUSTAS MSPT (NPI 1063508893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063508893 NPI number — AFTHALIA KOUSTAS MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOUSTAS
Provider First Name:
AFTHALIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1063508893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 MEETINGHOUSE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03110-6090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-644-8334
Provider Business Mailing Address Fax Number:
603-644-8339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 MEETINGHOUSE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03110-6090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-644-8334
Provider Business Practice Location Address Fax Number:
603-644-8339
Provider Enumeration Date:
10/05/2006

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:  2827 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT2827 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08Y004684NH02 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30394080 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA51080 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 9683166 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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