1164474334 NPI number — BAY STATE PHYSICAL THERAPY OF RANDOLPH INC

Table of content: (NPI 1164474334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164474334 NPI number — BAY STATE PHYSICAL THERAPY OF RANDOLPH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAY STATE PHYSICAL THERAPY OF RANDOLPH INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1164474334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
703 GRANITE ST STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRAINTREE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02184-5350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-961-3370
Provider Business Mailing Address Fax Number:
781-961-1291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
703 GRANITE ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRAINTREE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02184-5350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-961-3370
Provider Business Practice Location Address Fax Number:
781-961-1291
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINDWER
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
781-961-3370

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 689511 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9705601 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 626127 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0009411 . This is a "ALLWAYS HEALTHCARE (FORMERLY NHP)" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 684486 . This is a "OPTUM/UHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: PT0101 . This is a "MEDICARE PIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y61008 . This is a "BLUE CROSS BLUE SHIELD (MA)" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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