1104035302 NPI number — PLYMOUTH BAY ORTHOPEDIC ASSOCIATES, INC.

Table of content: (NPI 1104035302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104035302 NPI number — PLYMOUTH BAY ORTHOPEDIC ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLYMOUTH BAY ORTHOPEDIC ASSOCIATES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PLYMOUTH BAY ORTHOPEDIC & SPORTS THERAPY
Provider Other Organization Name Type Code:
5
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:
1104035302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 TREMONT ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
DUXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02332-4738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-934-7292
Provider Business Mailing Address Fax Number:
781-934-8112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41 RESNIK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360-4842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-934-7292
Provider Business Practice Location Address Fax Number:
508-746-3930
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OLIVER
Authorized Official First Name:
R SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
781-934-7292

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  259 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 259 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 9764984 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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