1548350481 NPI number — MARK A CONNAUGHTON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548350481 NPI number — MARK A CONNAUGHTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNAUGHTON
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1548350481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
118 OXBOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYLAND
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01778-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-287-3700
Provider Business Mailing Address Fax Number:
978-287-3729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
133 OLD ROAD TO NINE ACRE CORNER
Provider Second Line Business Practice Location Address:
RADIOLOGY DEPARTMENT
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01742-4159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-287-3700
Provider Business Practice Location Address Fax Number:
978-287-3729
Provider Enumeration Date:
10/13/2006

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: 2085R0202X , with the licence number:  54101 , 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: 3003256 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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