1306845672 NPI number — DR. YELENA MIKICH M.D.

Table of content: DR. YELENA MIKICH M.D. (NPI 1306845672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306845672 NPI number — DR. YELENA MIKICH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKICH
Provider First Name:
YELENA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1306845672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3550 MAIN ST STE 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01107-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-781-8290
Provider Business Mailing Address Fax Number:
413-732-7628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 MAIN ST STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01107-1088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-781-8290
Provider Business Practice Location Address Fax Number:
413-737-8540
Provider Enumeration Date:
07/19/2005

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: 207V00000X , with the licence number:  154223 , 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: 3170772 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 875845 . This is a "US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0011041 . This is a "NEIGHBORHOOD HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 154223 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 07-40454 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000006125 . This is a "BMC HEALTHNET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 130833 . This is a "PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 154223 . This is a "CONNECTICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 20583 . This is a "HEALTH NEW ENGLAND" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 160036619 . This is a "RR MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: MIJ18169 . This is a "BLUE SHIELD OF MASS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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