1124037361 NPI number — RANDOLPH D. MALONEY, M.D., PC

Table of content: DR. DAIHUNG JAY DUONG M.D. (NPI 1467480665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124037361 NPI number — RANDOLPH D. MALONEY, M.D., PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDOLPH D. MALONEY, M.D., PC
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:
NORTH SHORE VASCULAR DIAGNOSTIC LABORATORY
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:
1124037361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 HERRICK ST
Provider Second Line Business Mailing Address:
SUITE 110 - PARKHURST MEDICAL BLDG.
Provider Business Mailing Address City Name:
BEVERLY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01915-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-922-5535
Provider Business Mailing Address Fax Number:
978-922-5667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 HERRICK ST
Provider Second Line Business Practice Location Address:
SUITE 110 - PARKHURST MEDICAL BLDG.
Provider Business Practice Location Address City Name:
BEVERLY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01915-5900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-922-5535
Provider Business Practice Location Address Fax Number:
978-922-5667
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALONEY
Authorized Official First Name:
RANDOLPH
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
MEDICAL DIRECTOR PRESIDENT
Authorized Official Telephone Number:
978-922-5535

Provider Taxonomy Codes

  • Taxonomy code: 2471V0105X , with the licence number:  RDMS-RVT , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 293D00000X , with the licence number: 35297 , 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: 021569 . This is a "BLUECROSS/BLUESHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 801461 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9769706 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33434 . This is a "FALLON HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 950000914 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 606913 . This is a "HARVARD PILGRAM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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