1124009741 NPI number — MARIBETH WALLACE HALL CNM

Table of content: MARIBETH WALLACE HALL CNM (NPI 1124009741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124009741 NPI number — MARIBETH WALLACE HALL CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE HALL
Provider First Name:
MARIBETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
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:
1124009741
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 PLANTATION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605-2038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-368-3110
Provider Business Mailing Address Fax Number:
508-368-3113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 SUMMER ST
Provider Second Line Business Practice Location Address:
SUITE 150 S
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01608-1312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-368-3110
Provider Business Practice Location Address Fax Number:
508-368-3113
Provider Enumeration Date:
11/10/2005

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: 367A00000X , with the licence number:  146398 , 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: 04247226 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 420000565 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0381110 . This is a "MEDICAID/WELFARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9713805001 . This is a "CIGNA HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: CN0154 . This is a "BLUE CARE ELECT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2045900 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 47094 . This is a "CHILDRENS MED SECURITY PL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266039 . This is a "TRICARE/CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 61227 . This is a "FALLON COMMUNITY HLTH PL" identifier . This identifiers is of the category "OTHER".
  • Identifier: CN0154 . This is a "BLUE SHIELD INDEMNITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: RN0029 . This is a "MEDICARE B" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "HEALTHCARE VALUE MNGMENT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7956635 . This is a "AETNA/US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CN0154 . This is a "BLUE SHIELD HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472256 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "THREE RIVERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9713805001 . This is a "CIGNA PAL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA3471 . This is a "HARVARD PILGRIM HEALTHCAR" identifier . This identifiers is of the category "OTHER".




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