1093004137 NPI number — MS. REBECCA L BUCALA PT

Table of content: MS. REBECCA L BUCALA PT (NPI 1093004137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093004137 NPI number — MS. REBECCA L BUCALA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCALA
Provider First Name:
REBECCA
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
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:
YORK
Provider Other First Name:
REBECCA
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093004137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5700
Provider Second Line Business Mailing Address:
VALLEY MEDICA GROUP, P.C.
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-5700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-431-4077
Provider Business Mailing Address Fax Number:
413-774-7448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
329 CONWAY ST
Provider Second Line Business Practice Location Address:
GREENFIELD HEALTH CENTER
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01301-1521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-774-6301
Provider Business Practice Location Address Fax Number:
413-772-6390
Provider Enumeration Date:
03/29/2011

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:  17828 , 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: 9315709 . This is a "AETNA/US HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 93592801 . This is a "NETWORK HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110088469A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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