1194077909 NPI number — ROSE ANN BERWALD, M.D.

Table of content: (NPI 1194077909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194077909 NPI number — ROSE ANN BERWALD, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE ANN BERWALD, M.D.
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:
1194077909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
966 PARK ST STE B2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOUGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02072-3650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-344-7673
Provider Business Mailing Address Fax Number:
781-344-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
966 PARK ST STE B2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOUGHTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02072-3650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-344-7673
Provider Business Practice Location Address Fax Number:
781-344-5955
Provider Enumeration Date:
10/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BERWALD
Authorized Official First Name:
ROSE ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
781-344-7673

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  70519 , 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: 070519 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 32136 . This is a "AETNA/US HEALTCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: B21216 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110047284/A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13564 . This is a "HARVARD PILGRIM HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J08817 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3065320 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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