1912930330 NPI number — VITREO-RETINAL ASSOCIATES OF WORCESTER PC

Table of content: JORDAN MATTHEW MCCALL LPCA (NPI 1407581804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912930330 NPI number — VITREO-RETINAL ASSOCIATES OF WORCESTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITREO-RETINAL ASSOCIATES OF WORCESTER 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:
1912930330
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:
67 BELMONT ST
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605-2657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-752-1155
Provider Business Mailing Address Fax Number:
508-752-4862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67 BELMONT ST
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01605-2657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-752-1155
Provider Business Practice Location Address Fax Number:
508-752-4862
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RHEAUME
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
508-752-1155

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9723838 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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