1114914868 NPI number — MERRIMACK VALLEY MEDICAL ASSOCIATES, PC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114914868 NPI number — MERRIMACK VALLEY MEDICAL ASSOCIATES, PC

Employer Identification Number (EIN):

Provider Organization Name:

MERRIMACK VALLEY MEDICAL ASSOCIATES, 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 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:

1114914868

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

09/28/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 3160

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ANDOVER

Provider Business Mailing Address State Name:

MA

Provider Business Mailing Address Postal Code:

01810-0803

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

978-289-1188

Provider Business Mailing Address Fax Number:

978-474-8845

Provider First Line Business Practice Location Address:

421 MERRIMACK ST

Provider Second Line Business Practice Location Address:

SUITE 201

Provider Business Practice Location Address City Name:

METHUEN

Provider Business Practice Location Address State Name:

MA

Provider Business Practice Location Address Postal Code:

01844-5803

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

978-725-4822

Provider Business Practice Location Address Fax Number:

978-725-5277

Provider Enumeration Date:

09/27/2005

Authorized Official Last Name:

LANE

Authorized Official First Name:

LEO

Authorized Official Middle Name:

WILLIAM

Authorized Official Title or Position:

OWNER

Authorized Official Telephone Number:

978-725-4822

• Taxonomy code: 207R00000X , with the licence number:  155341 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 2301962 . This is a "AETNA US HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 3208621 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
• Identifier: 50493 . This is a "MATTHEW THORNTON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 9593735010 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 504290 . This is a "CIGNA HEALTHSOURCE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 155341 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 69499 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 2301962 . This is a "US HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 49241 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 504290 . This is a "HEALTH SOURCE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: M18024 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".