1114986361 NPI number — RUSSELL FRADKIN OD

Table of content: RUSSELL FRADKIN OD (NPI 1114986361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114986361 NPI number — RUSSELL FRADKIN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRADKIN
Provider First Name:
RUSSELL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

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:
1114986361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
999 PROVIDENCE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITINSVILLE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-234-6681
Provider Business Mailing Address Fax Number:
508-234-6507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 PROVIDENCE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITINSVILLE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-234-6681
Provider Business Practice Location Address Fax Number:
508-234-6507
Provider Enumeration Date:
03/17/2006

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: 152W00000X , with the licence number:  2699 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 725524 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W15622 . This is a "BLUE CROSS OF MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0333913 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6000000019 . This is a "HARVARD PILGRIM HEALTHCAR" identifier . This identifiers is of the category "OTHER".
  • Identifier: W20190 . This is a "BLUE CROSS OF MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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