1790875169 NPI number — MARCIA L DENINE NP

Table of content: MARCIA L DENINE NP (NPI 1790875169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790875169 NPI number — MARCIA L DENINE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENINE
Provider First Name:
MARCIA
Provider Middle Name:
L
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:
1790875169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1619
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST TISBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02575-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-627-5797
Provider Business Mailing Address Fax Number:
508-627-5799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 EDGARTOWN VINEYARD HAVEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGARTOWN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02539-6941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-627-5797
Provider Business Practice Location Address Fax Number:
508-627-5799
Provider Enumeration Date:
10/13/2006

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: 363LW0102X , with the licence number:  250377 , 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: 0711101 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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