1407802804 NPI number — GREATER LOWELL PET PC

Table of content: (NPI 1407802804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407802804 NPI number — GREATER LOWELL PET PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER LOWELL PET PC
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:
NEW ENGLAND PET OF GREATER LOWELL
Provider Other Organization Name Type Code:
3
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:
1407802804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
354 MERRIMACK ST
Provider Second Line Business Mailing Address:
ENTRANCE D
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01843-1754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-687-8187
Provider Business Mailing Address Fax Number:
978-687-8185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
295 VARNUM AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LOWELL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01854-2134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-458-9872
Provider Business Practice Location Address Fax Number:
978-458-9876
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
MARK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
978-687-2321

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  67-0397 , 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: 699024 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3184313 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: M18082 . This is a "BLUE CROSS OF MA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0029226 . This is a "NEIGHBORHOOD HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 626417 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9726730 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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