1326053786 NPI number — MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.

Table of content: (NPI 1326053786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326053786 NPI number — MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.
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:
1326053786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 W CUMMINGS PARK
Provider Second Line Business Mailing Address:
SUITE 4700
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801-6372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-224-0661
Provider Business Mailing Address Fax Number:
781-224-1993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 W CUMMINGS PARK
Provider Second Line Business Practice Location Address:
SUITE 4700
Provider Business Practice Location Address City Name:
WOBURN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01801-6372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-224-0661
Provider Business Practice Location Address Fax Number:
781-224-1993
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TISSERA
Authorized Official First Name:
LALITH
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
781-224-0661

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  81635 , 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: 3143741 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007792 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M21864 . This is a "MEDICARE PIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: G10083 . This is a "MEDICARE UPIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 007792 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 3143741 . This is a "MEDICAID" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 776747 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M19048 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 222936 . This is a "PACIFICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: A20487 . This is a "MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J16485 . This is a "BLUECROSSBLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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