1093786725 NPI number — DEMOS AGIOMAVRITIS MD PC

Table of content: (NPI 1093786725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093786725 NPI number — DEMOS AGIOMAVRITIS MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEMOS AGIOMAVRITIS MD PC
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:
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:
1093786725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
385 GROVE ST
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605-3924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-770-8002
Provider Business Mailing Address Fax Number:
508-770-8006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
385 GROVE ST
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01605-3924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-770-8002
Provider Business Practice Location Address Fax Number:
508-770-8006
Provider Enumeration Date:
01/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
AGIOMAVRITIS
Authorized Official First Name:
DEMOSTHENES
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PHYSICIAN PRESIDENT
Authorized Official Telephone Number:
508-770-8002

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  47165 , 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: 61250 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9065240 . This is a "PRIVATE HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20787175 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 26373 . This is a "FALLON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 701827 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 999969 . This is a "NETWORK HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9751530 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: N01922 . This is a "BLUE CROSS INDIVIDUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: M18983 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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