1083010029 NPI number — CHANEY FISHER

Table of content: CHANEY FISHER (NPI 1083010029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083010029 NPI number — CHANEY FISHER

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1083010029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 ROYAL CREST DR APT 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH ANDOVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01845-6409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-244-0081
Provider Business Mailing Address Fax Number:
401-921-3327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 PLEASANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03301-3948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-224-3346
Provider Business Practice Location Address Fax Number:
603-224-2149
Provider Enumeration Date:
11/18/2014

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: 237700000X , with the licence number:  296 , 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: 1598891855 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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