1184613275 NPI number — OVERLOOK MASONIC HEALTH CENTER INC

Table of content: (NPI 1184613275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184613275 NPI number — OVERLOOK MASONIC HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OVERLOOK MASONIC HEALTH CENTER 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:
1184613275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
88 MASONIC HOME RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01507-1394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-248-7344
Provider Business Mailing Address Fax Number:
508-248-7989

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
88 MASONIC HOME RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01507-1394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-248-7344
Provider Business Practice Location Address Fax Number:
508-248-7989
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
508-434-2412

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0749 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0918822 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2222564301 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720724 . This is a "MEDICAID TRANSPORTATION" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 15030 . This is a "FALLON COMMUNITY HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 71-01273 . This is a "UNITED HEALTHCARE/EVERCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 905879 . This is a "HARVARD PILGRIM HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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