1164477055 NPI number — 4499 ACUSHNET AVENUE OPERATING COMPANY, LLC

Table of content: (NPI 1164477055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164477055 NPI number — 4499 ACUSHNET AVENUE OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
4499 ACUSHNET AVENUE OPERATING COMPANY, LLC
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:
VIBRA HOSPITAL OF SOUTHEASTERN MASSACHUSETTS
Provider Other Organization Name Type Code:
5
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:
1164477055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4499 ACUSHNET AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02745-4707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-995-6900
Provider Business Mailing Address Fax Number:
508-998-5974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4499 ACUSHNET AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02745-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-995-6900
Provider Business Practice Location Address Fax Number:
508-985-9615
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLINGER
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
717-591-5700

Provider Taxonomy Codes

  • Taxonomy code: 282E00000X , with the licence number:  079 , 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: 982810 . This is a "TUFTS INPATIENT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2222204301 . This is a "BLUE CROSS INPATIENT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 982813 . This is a "TUFTS OUTPATIENT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1100548 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2222204310 . This is a "BLUE CROSS (OUTPATIENT)" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 5000016 . This is a "UNITED HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1100556 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1213393 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 903949 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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