1144223074 NPI number — MEDWAY COUNTRY MANOR, INC.

Table of content: (NPI 1144223074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144223074 NPI number — MEDWAY COUNTRY MANOR, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDWAY COUNTRY MANOR, INC.
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:
MEDWAY COUNTRY MANOR SKILLED NURSING & REHABILITATION
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:
1144223074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 HOLLISTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDWAY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02053-1954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-533-6634
Provider Business Mailing Address Fax Number:
508-533-7048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 HOLLISTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDWAY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02053-1954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-533-6634
Provider Business Practice Location Address Fax Number:
508-533-7048
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SIMHA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
917-885-7050

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  0840 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 0840 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 0840 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 0840 , 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: 0461870001 . This is a "NSC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0910481 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2222541201 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: SG0026 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y61422 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: OG0035 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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