1073858981 NPI number — HEIDI GLOVER HEIDI GLOVER

Table of content: HEIDI GLOVER HEIDI GLOVER (NPI 1073858981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073858981 NPI number — HEIDI GLOVER HEIDI GLOVER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLOVER
Provider First Name:
HEIDI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HEIDI GLOVER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLOVER
Provider Other First Name:
HEIDI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP BC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1073858981
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 LAKE AVE NORTH DEPT. OF PEDI-ADOLESCENT
Provider Second Line Business Mailing Address:
U MASS MEMORIAL MEDICAL CENTER, UNIVERSITY CAMPUS,
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
744-442-5624
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 LAKE AVE NORTH DEPT. OF PEDI-ADOLESCENT
Provider Second Line Business Practice Location Address:
UMMC UNIVERSITY CAMPUS
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
744-442-5624
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/04/2012

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: 363LF0000X , with the licence number:  226121 , 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)





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