1124019765 NPI number — MARY MCGAUGH M.D.

Table of content: MARY MCGAUGH M.D. (NPI 1124019765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124019765 NPI number — MARY MCGAUGH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGAUGH
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1124019765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
191 INDEPENDENCE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02169-7751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-773-5070
Provider Business Mailing Address Fax Number:
617-472-2380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
191 INDEPENDENCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02169-7751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-773-5070
Provider Business Practice Location Address Fax Number:
617-472-2380
Provider Enumeration Date:
11/02/2005

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: 208000000X , with the licence number:  75412 , 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: 075412 . This is a "TUFHTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3092887 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J12178 . This is a "BLUE SHIELD OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 20728 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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