1023054657 NPI number — NAI SATURN EASTERN LLC

Table of content: (NPI 1023054657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023054657 NPI number — NAI SATURN EASTERN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAI SATURN EASTERN LLC
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:
6
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:
1023054657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 E PARKCENTER BLVD
Provider Second Line Business Mailing Address:
MAILSTOP SEC2-B
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83706-3940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-916-4463
Provider Business Mailing Address Fax Number:
847-916-4736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2610 BOSTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224-3667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-675-3802
Provider Business Practice Location Address Fax Number:
410-675-3769
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELIOPULOS
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT MANAGER, ENROLLMENTS
Authorized Official Telephone Number:
208-395-3906

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: P06603 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2149964 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 651010800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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