1487659694 NPI number — SECON OF NEW ENGLAND LLC

Table of content: (NPI 1487659694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487659694 NPI number — SECON OF NEW ENGLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SECON OF NEW ENGLAND LLC
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:
1487659694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 830525
Provider Second Line Business Mailing Address:
#OWC 30
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35283-0525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-304-7602
Provider Business Mailing Address Fax Number:
508-304-7602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 MAIN ST
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01608-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-831-0703
Provider Business Practice Location Address Fax Number:
508-831-0803
Provider Enumeration Date:
06/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FREEMAN
Authorized Official First Name:
SYLVIA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
MGR OF CREDENTIALING/ENROLLMENT
Authorized Official Telephone Number:
508-304-7602

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  2465 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0007640552 . This is a "AETNA PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200024710A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41933 . This is a "FALLON PIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: TR0084 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4401024 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 691566 . This is a "TUFTS HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0816931 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000027970 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30803284 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 119364000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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