1689903882 NPI number — MYSTIC VALLEY UROLOGICAL ASSOC INC

Table of content: (NPI 1689903882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689903882 NPI number — MYSTIC VALLEY UROLOGICAL ASSOC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYSTIC VALLEY UROLOGICAL ASSOC INC
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:
1689903882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 WOODLAND RD
Provider Second Line Business Mailing Address:
SUITE 216
Provider Business Mailing Address City Name:
STONEHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02180-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-979-0661
Provider Business Mailing Address Fax Number:
781-979-0372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 WOODLAND RD
Provider Second Line Business Practice Location Address:
SUITE 216
Provider Business Practice Location Address City Name:
STONEHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02180-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-979-0661
Provider Business Practice Location Address Fax Number:
781-979-0372
Provider Enumeration Date:
12/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HALUSKA
Authorized Official First Name:
MARJIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS OPERATIONS
Authorized Official Telephone Number:
781-979-0661

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , 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: 0009638 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9723757 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M13568 . This is a "BCBSMA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M13568 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9723757 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 28749 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 600296 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: CL0638 . This is a "RRMED" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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