1124142021 NPI number — DR. MARIA BERSTEIN BRUCCULERI ED.D

Table of content: DR. MARIA BERSTEIN BRUCCULERI ED.D (NPI 1124142021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124142021 NPI number — DR. MARIA BERSTEIN BRUCCULERI ED.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUCCULERI
Provider First Name:
MARIA
Provider Middle Name:
BERSTEIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED.D
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:
1124142021
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:
16 DARLENE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01772-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-787-9713
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01772-1661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-787-9713
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2007

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: 103TC1900X , with the licence number:  6504 , 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: 7428353 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 455196 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 6162351 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W06109 . This is a "BCBS INDEMNITY" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1005820 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 013120 . This is a "HARVARD PILGRIM HEALTH CA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 52402 . This is a "FALLON COMMUNITY HEALTH P" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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