1497749410 NPI number — MR. CARL BRUCE LEDIG MD

Table of content: JOSH C MINJAREZ APRN (NPI 1063230555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497749410 NPI number — MR. CARL BRUCE LEDIG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEDIG
Provider First Name:
CARL
Provider Middle Name:
BRUCE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1497749410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 ENDICOTT ST
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
DANVERS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01923-3623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-882-6868
Provider Business Mailing Address Fax Number:
978-882-6855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 ENDICOTT ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
DANVERS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01923-3623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-882-6868
Provider Business Practice Location Address Fax Number:
978-882-6855
Provider Enumeration Date:
09/06/2005

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: 208600000X , with the licence number:  704082 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X , with the licence number: 704082 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2062321 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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