1457536997 NPI number — BIOSERENITY DT, INC.

Table of content: (NPI 1457536997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457536997 NPI number — BIOSERENITY DT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIOSERENITY DT, INC.
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:
1457536997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 ROSEWOOD DR STE 245
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVERS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01923-4537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-536-7400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1003 EASTON RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WILLOW GROVE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-543-6800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SHOCK
Authorized Official First Name:
JANICE
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP CLINICAL OPERATIONS
Authorized Official Telephone Number:
214-532-3757

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7618325 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000020417 . This is a "HIGHMARK - BC/BS OF PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0658107000 . This is a "AMERIHEALTH HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0658107000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0453320000 . This is a "AMERIHEALTH PERS CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0453320000 . This is a "BC/BS PERSONAL CHOICE PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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