1124418058 NPI number — MIKHAIL NOVIKOV MD PC

Table of content: (NPI 1124418058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124418058 NPI number — MIKHAIL NOVIKOV MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIKHAIL NOVIKOV MD 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:
DR. NOVIKOV WELLNESS AND SKIN CARE
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:
1124418058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 THADDEUS MASON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01532-2284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-209-7823
Provider Business Mailing Address Fax Number:
617-336-3306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
318 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-936-1657
Provider Business Practice Location Address Fax Number:
888-355-3778
Provider Enumeration Date:
01/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NOVIKOV
Authorized Official First Name:
MIKHAIL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
508-936-1657

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  241998 , 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: 110109342A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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