1114979580 NPI number — THE MCLEAN HOSPITAL CORPORATION

Table of content: (NPI 1114979580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114979580 NPI number — THE MCLEAN HOSPITAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MCLEAN HOSPITAL CORPORATION
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:
MCLEAN PROFESSIONAL PRACTICE GROUP
Provider Other Organization Name Type Code:
3
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:
1114979580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 5-0397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01815-0397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-855-2183
Provider Business Mailing Address Fax Number:
617-855-3745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 MILL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELMONT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02478-1041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-855-2183
Provider Business Practice Location Address Fax Number:
617-855-3745
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOLD
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
617-855-2367

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 9778705 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M16400 . This is a "BC/BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1201174 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W10374 . This is a "BC/BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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