1174776058 NPI number — BUZZARDS BAY CHIROPRACTIC, P.C.

Table of content: (NPI 1174776058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174776058 NPI number — BUZZARDS BAY CHIROPRACTIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUZZARDS BAY CHIROPRACTIC, P.C.
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:
6
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:
1174776058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUZZARDS BAY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-759-8852
Provider Business Mailing Address Fax Number:
508-759-0192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUZZARDS BAY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-759-8852
Provider Business Practice Location Address Fax Number:
508-759-0192
Provider Enumeration Date:
10/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
508-759-8852

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  MA1748 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NX0800X , with the licence number: MA1748 , 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: 4400497 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 954853 . This is a "AETNA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 35264 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 954853 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: Y36232 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1610627 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 768825 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4400497 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 57566 . This is a "CIGNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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