1639183924 NPI number — BARBARA A POREMBA NP

Table of content: BARBARA A POREMBA NP (NPI 1639183924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639183924 NPI number — BARBARA A POREMBA NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POREMBA
Provider First Name:
BARBARA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1639183924
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:
77 HERRICK ST
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
BEVERLY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01915-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-927-4110
Provider Business Mailing Address Fax Number:
978-232-7057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 HERRICK ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
BEVERLY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01915-3012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-927-4110
Provider Business Practice Location Address Fax Number:
978-232-7057
Provider Enumeration Date:
07/29/2006

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:  NP114394 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP2265 . This is a "BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0703503 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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