1083605638 NPI number — DR. JOANNE OMALLEY SHEPARD MD

Table of content: DR. JOANNE OMALLEY SHEPARD MD (NPI 1083605638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083605638 NPI number — DR. JOANNE OMALLEY SHEPARD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEPARD
Provider First Name:
JOANNE
Provider Middle Name:
OMALLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1083605638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9142
Provider Second Line Business Mailing Address:
MASS GENERAL PHYSICIAN ORGANIZATION
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02129-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-724-4256
Provider Business Mailing Address Fax Number:
617-724-0046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 FRUIT STREET
Provider Second Line Business Practice Location Address:
FND 2
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-2696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-724-4256
Provider Business Practice Location Address Fax Number:
617-724-0046
Provider Enumeration Date:
11/02/2005

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: 2085R0202X , with the licence number:  43700 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: 211708 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 014403 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0145904 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 724090 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: C05306 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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