1538222716 NPI number — MRS. ANN BERGAN FITZGERALD LICSW

Table of content: (NPI 1750766945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538222716 NPI number — MRS. ANN BERGAN FITZGERALD LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
ANN
Provider Middle Name:
BERGAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERGAN
Provider Other First Name:
ANN
Provider Other Middle Name:
GRETCHEN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538222716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
173 CHELSEA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-861-0890
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 CABOT RD FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-5177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-393-5152
Provider Business Practice Location Address Fax Number:
781-393-5168
Provider Enumeration Date:
12/18/2006

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: 1041C0700X , with the licence number:  110624 , 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: 1538222716 . This is a "UBH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518164508 . This is a "FALLON COMMUNITY HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 12515715 . This is a "MULTI-PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518164508 . This is a "MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518164508 . This is a "MBHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1518164508 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 486325 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9186232 . This is a "PHCS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 987309-02 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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