1104927003 NPI number — MEDICAL PSYCHOLOGY CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104927003 NPI number — MEDICAL PSYCHOLOGY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL PSYCHOLOGY CENTER, LLC
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:
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:
1104927003
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CUMMINGS CTR
Provider Second Line Business Mailing Address:
SUITE 456J
Provider Business Mailing Address City Name:
BEVERLY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01915-6106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-921-4000
Provider Business Mailing Address Fax Number:
978-921-7530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 CUMMINGS CTR
Provider Second Line Business Practice Location Address:
SUITE 456J
Provider Business Practice Location Address City Name:
BEVERLY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01915-6106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-921-4000
Provider Business Practice Location Address Fax Number:
978-921-7530
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
INZ
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
978-921-4000

Provider Taxonomy Codes

  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7218197 . This is a "AETNA - PPO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 644966 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W10659 . This is a "BC BS OF MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 311164 . This is a "MANAGED HEALTH NETWORK" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1135317 . This is a "AETNA - HMO" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2059722 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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