1114140985 NPI number — PETER G. SPENCER PH.D.

Table of content: PETER G. SPENCER PH.D. (NPI 1114140985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114140985 NPI number — PETER G. SPENCER PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
PETER
Provider Middle Name:
G.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1114140985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 LARKSPUR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01002-3440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-256-6733
Provider Business Mailing Address Fax Number:
413-253-4089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48 N PLEASANT ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01002-1738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-253-1766
Provider Business Practice Location Address Fax Number:
413-253-4089
Provider Enumeration Date:
04/10/2007

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: 103TC0700X , with the licence number:  4972 , 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: 4972 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3529-9096 . This is a "APA MEMBERSHIP NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: W04700 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41071 . This is a "NAT. REGISTRY NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0522503 . This is a "MASS HEALTH PROVIDER NO." identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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