1326042995 NPI number — DR. LEE EDWARD GUERTIN III O.D.

Table of content: DR. LEE EDWARD GUERTIN III O.D. (NPI 1326042995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326042995 NPI number — DR. LEE EDWARD GUERTIN III O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUERTIN
Provider First Name:
LEE
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
O.D.
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:
1326042995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
86 PURGATORY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUTTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01590-2803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-865-0696
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 COUNTY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02726-4240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-676-8167
Provider Business Practice Location Address Fax Number:
508-676-1434
Provider Enumeration Date:
06/10/2005

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: 152W00000X , with the licence number:  MG0358033M (TPA) , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4074 , 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: 110024738A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W16263 . This is a "BCBS MASSACHUSETTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 152748 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 22-00849 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 454708 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 411983 . This is a "BCBS RI BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 0702102 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23640-7 . This is a "BCBS RHODE ISLAND" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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