1598770984 NPI number — PSYCH CARE ASSOC PC

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 1598770984 NPI number — PSYCH CARE ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCH CARE ASSOC PC
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:
1598770984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 WINSOR ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LUDLOW
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01056-3469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-583-6750
Provider Business Mailing Address Fax Number:
413-589-7001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 WINSOR ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LUDLOW
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01056-3469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-583-6750
Provider Business Practice Location Address Fax Number:
413-589-7001
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
QAYYUM
Authorized Official First Name:
USMAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
413-583-6750

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: BCBS OF MA . This is a "M19012" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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