1124136510 NPI number — WOBURN PEDIATRIC ASSOCIATES

Table of content: (NPI 1124136510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124136510 NPI number — WOBURN PEDIATRIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOBURN PEDIATRIC ASSOCIATES
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:
Provider Other Organization Name Type Code:
6
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:
1124136510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 ALFRED ST
Provider Second Line Business Mailing Address:
BALDWIN PARK II
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801-1976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-933-6236
Provider Business Mailing Address Fax Number:
781-938-8050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 ALFRED ST
Provider Second Line Business Practice Location Address:
BALDWIN PARK II
Provider Business Practice Location Address City Name:
WOBURN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01801-1976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-933-6236
Provider Business Practice Location Address Fax Number:
781-938-8050
Provider Enumeration Date:
08/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETRARCA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
781-638-1020

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9712623 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25114 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 805422 . This is a "TUFTS HEALTH PLAN - LAB" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M12470 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 600388 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9110 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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