1124541834 NPI number — MS. REBECCA ANNE VANDERWALL MS, MPH

Table of content: (NPI 1063055085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124541834 NPI number — MS. REBECCA ANNE VANDERWALL MS, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERWALL
Provider First Name:
REBECCA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, MPH
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:
1124541834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 BROOKLINE AVE # DA1040
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02215-5418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-582-8537
Provider Business Mailing Address Fax Number:
617-582-8305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 BROOKLINE AVENUE
Provider Second Line Business Practice Location Address:
DA 1040
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-582-8537
Provider Business Practice Location Address Fax Number:
617-582-8305
Provider Enumeration Date:
07/25/2017

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: 170300000X , with the licence number:  GC368 , 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)





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