1922055094 NPI number — MERRIMACK VALLEY PET PC

Table of content: (NPI 1922055094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922055094 NPI number — MERRIMACK VALLEY PET PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRIMACK VALLEY PET 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:
NEW ENGLAND PET IMAGING SYSTEM
Provider Other Organization Name Type Code:
3
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:
1922055094
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
354 MERRIMACK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01843-1754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-687-8187
Provider Business Mailing Address Fax Number:
978-687-8185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 QUEEN CITY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03101-7121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-663-2370
Provider Business Practice Location Address Fax Number:
603-663-2379
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
MARK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
978-687-2321

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X , with the licence number:  446R , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 15Y002275MA02 . This is a "BLUE CROSS OF NH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 626241 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 685730 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3184391 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30813476 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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