1174674279 NPI number — DR. JONATHAN DAVID BIRNBERG PH.D.

Table of content: DR. JONATHAN DAVID BIRNBERG PH.D. (NPI 1174674279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174674279 NPI number — DR. JONATHAN DAVID BIRNBERG PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRNBERG
Provider First Name:
JONATHAN
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1174674279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
332 POOL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIDDEFORD
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04005-9713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-775-2220
Provider Business Mailing Address Fax Number:
207-775-2226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-5453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-775-2220
Provider Business Practice Location Address Fax Number:
207-775-2226
Provider Enumeration Date:
01/15/2007

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: 103T00000X , with the licence number:  PS1192 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: 8077 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: W06273 . This is a "BCBS OF MASS." identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0005266 . This is a "MEDICARE PTAN" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 808393000 . This is a "MAGELLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".