1548268535 NPI number — NORTHSHORE PLASTIC SURGERY, LLC

Table of content: (NPI 1548268535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548268535 NPI number — NORTHSHORE PLASTIC SURGERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSHORE PLASTIC SURGERY, 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:
1548268535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 MAIN ST
Provider Second Line Business Mailing Address:
STE. 670
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01608-1604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-754-3566
Provider Business Mailing Address Fax Number:
508-798-8012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 CENTENNIAL DR
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PEABODY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01960-7935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-531-6966
Provider Business Practice Location Address Fax Number:
978-531-2221
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WAGES
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-531-6966

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , 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: 9707573 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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