1154355725 NPI number — MASS BAY SPINE & SPORT PHYSICAL THERAPY, INC.

Table of content: (NPI 1154355725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154355725 NPI number — MASS BAY SPINE & SPORT PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASS BAY SPINE & SPORT PHYSICAL THERAPY, 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:
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:
1154355725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 PLAIN ST
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
MARSHFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02050-2744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-319-0024
Provider Business Mailing Address Fax Number:
781-319-0088

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 PLAIN ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
MARSHFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02050-2744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-319-0024
Provider Business Practice Location Address Fax Number:
781-319-0088
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CARMAN
Authorized Official First Name:
BRENDAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
781-319-0024

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  15242 , 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: AA40694 . This is a "HARVARD PILGRIM HEALTHCAR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y61429 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 441368 . This is a "TUFTS HEALTHPLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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