1487665402 NPI number — BIOSERENITY DT INC.

Table of content: (NPI 1487665402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487665402 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:
1487665402
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:
978-535-9757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
386 N YORK ST STE 207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMHURST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60126-2367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-699-5176
Provider Business Practice Location Address Fax Number:
847-966-7316
Provider Enumeration Date:
08/11/2006

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: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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: 01619296 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 8011510 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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