1033546700 NPI number — HAIDANG TRUONG KELLY NP

Table of content: HAIDANG TRUONG KELLY NP (NPI 1033546700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033546700 NPI number — HAIDANG TRUONG KELLY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
HAIDANG
Provider Middle Name:
TRUONG
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:
TRUONG
Provider Other First Name:
HAIDANG
Provider Other Middle Name:
THI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033546700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 MILK ST FL 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02109-4806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
147 MILK ST FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-654-7280
Provider Business Practice Location Address Fax Number:
617-654-7363
Provider Enumeration Date:
09/26/2013

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: 363LA2200X , with the licence number:  RN2263216 , 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: 110022129 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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