1164403275 NPI number — ELIZABETH M CHU HANSON MD

Table of content: ELIZABETH M CHU HANSON MD (NPI 1164403275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164403275 NPI number — ELIZABETH M CHU HANSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHU HANSON
Provider First Name:
ELIZABETH
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164403275
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:
77 WARREN STREET, 3RD FL
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT DEPT
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-562-5359
Provider Business Mailing Address Fax Number:
617-562-5415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 OAK STREET
Provider Second Line Business Practice Location Address:
SUITE 123E
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-526-5359
Provider Business Practice Location Address Fax Number:
617-562-5415
Provider Enumeration Date:
11/07/2005

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: 363L00000X , with the licence number:  133138 , 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: 0366650 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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