1174614556 NPI number — KAREN MARIE BANNON BOISVERT D.C.

Table of content: KAREN MARIE BANNON BOISVERT D.C. (NPI 1174614556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174614556 NPI number — KAREN MARIE BANNON BOISVERT D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANNON BOISVERT
Provider First Name:
KAREN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BANNON
Provider Other First Name:
KAREN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174614556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03801-3826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-781-4774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 STATE ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03801-4370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-430-7744
Provider Business Practice Location Address Fax Number:
603-436-6729
Provider Enumeration Date:
09/28/2006

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: 111N00000X , with the licence number:  163-0494 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0506836YONH01 . This is a "ANTHEM BCBS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 424750 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 424750 . This is a "HEALTHSOURCE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 471703 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 1847758 . This is a "FIRST HEALTH" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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