1184615700 NPI number — DR. BRADFORD CLARK DICKERSON MD

Table of content: DR. BRADFORD CLARK DICKERSON MD (NPI 1184615700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184615700 NPI number — DR. BRADFORD CLARK DICKERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
BRADFORD
Provider Middle Name:
CLARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1184615700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 13TH ST
Provider Second Line Business Mailing Address:
SUITE 2691
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02129-2020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-724-6557
Provider Business Mailing Address Fax Number:
617-726-5760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 PARKMAN ST
Provider Second Line Business Practice Location Address:
WACC 835
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-726-1728
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2005

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: 2084N0400X , with the licence number:  216084 , 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: 2018811 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J26662 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 216084 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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