1134116270 NPI number — DR. RICHARD G SELBST M.D.

Table of content: DR. RICHARD G SELBST M.D. (NPI 1134116270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134116270 NPI number — DR. RICHARD G SELBST M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELBST
Provider First Name:
RICHARD
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1134116270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
354 MERRIMACK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01843-1754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-687-2321
Provider Business Mailing Address Fax Number:
978-685-7265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 MERRIMACK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01843-1754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-687-2321
Provider Business Practice Location Address Fax Number:
978-685-7265
Provider Enumeration Date:
10/04/2005

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: 2084N0400X , with the licence number:  49677 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0400X , with the licence number: 6606 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0167703 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05-00255 . This is a "EVERCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 05-00022 . This is a "UHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 11731 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4460335 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 715264 . This is a "THP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0003751 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: D02067 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 00000166 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0102760Y0MA01 . This is a "ANTHEM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 1127308-001 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 23597 . This is a "FCHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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