1568438729 NPI number — MS. MARY C CASSIDY N.P.

Table of content: MS. MARY C CASSIDY N.P. (NPI 1568438729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568438729 NPI number — MS. MARY C CASSIDY N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASSIDY
Provider First Name:
MARY
Provider Middle Name:
C
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

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:
1568438729
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 READVILLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02136-2040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-361-1173
Provider Business Mailing Address Fax Number:
617-361-1173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 KENT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02445-7901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-447-2147
Provider Business Practice Location Address Fax Number:
617-264-9763
Provider Enumeration Date:
02/27/2006

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: 363LA2200X , with the licence number:  129190 , 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: 0347001 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP2539 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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