1710905237 NPI number — AUTUMN GRACE MEDICAL ASSOCIATES, PC

Table of content: (NPI 1710905237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710905237 NPI number — AUTUMN GRACE MEDICAL ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUTUMN GRACE MEDICAL ASSOCIATES, 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:
1710905237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
188 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
METHUEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01844-3862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-682-3939
Provider Business Mailing Address Fax Number:
978-686-9494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
188 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
METHUEN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01844-3862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-682-3939
Provider Business Practice Location Address Fax Number:
978-686-9494
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YEH
Authorized Official First Name:
CHIH
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
978-682-3939

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  080819 , 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: 91248 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9734571 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2609134 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 625144 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 04-10314 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5667662 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 65440 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M18876 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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