1427056225 NPI number — KATHLEEN HOLLY GALLIVAN MD,MPH,FACS

Table of content: KATHLEEN HOLLY GALLIVAN MD,MPH,FACS (NPI 1427056225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427056225 NPI number — KATHLEEN HOLLY GALLIVAN MD,MPH,FACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLIVAN
Provider First Name:
KATHLEEN
Provider Middle Name:
HOLLY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD,MPH,FACS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DORR
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
HOLLY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD, MPH, FACS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1427056225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 TRADECENTER
Provider Second Line Business Mailing Address:
SUITE 750
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801-1851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-937-3001
Provider Business Mailing Address Fax Number:
781-305-2779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 TRADECENTER
Provider Second Line Business Practice Location Address:
SUITE 750
Provider Business Practice Location Address City Name:
WOBURN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01801-1851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-937-3001
Provider Business Practice Location Address Fax Number:
781-305-2779
Provider Enumeration Date:
07/14/2005

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: 207Y00000X , with the licence number:  204711 , 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: 0109100 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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