1992827695 NPI number — KIMBERLY RUSSO CASH PT

Table of content: KIMBERLY RUSSO CASH PT (NPI 1992827695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992827695 NPI number — KIMBERLY RUSSO CASH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASH
Provider First Name:
KIMBERLY
Provider Middle Name:
RUSSO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUSSO
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992827695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 BANKS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTHROP
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02152-1931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-846-5609
Provider Business Mailing Address Fax Number:
617-539-0025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 BANKS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTHROP
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02152-1931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-846-5609
Provider Business Practice Location Address Fax Number:
617-539-0025
Provider Enumeration Date:
04/04/2007

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: 225100000X , with the licence number:  16429 , 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: Y68361 . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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