1134105646 NPI number — MR. MATTHEW J TIERNEY D.O.

Table of content: MR. MATTHEW J TIERNEY D.O. (NPI 1134105646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134105646 NPI number — MR. MATTHEW J TIERNEY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIERNEY
Provider First Name:
MATTHEW
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1134105646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
46 OBERY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-2237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-746-6385
Provider Business Mailing Address Fax Number:
508-747-6685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 OBERY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360-2237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-746-6385
Provider Business Practice Location Address Fax Number:
508-747-6685
Provider Enumeration Date:
12/16/2005

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: 208600000X , with the licence number:  217632 , 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: J27151 . This is a "BCBSMA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3657254 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA15261 . This is a "HARVARD PILGRIM HEALTHCAR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2036070 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 468752 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1701676 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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