1184380099 NPI number — IMAGINE PRIMARY CARE, PC

Table of content: (NPI 1184380099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184380099 NPI number — IMAGINE PRIMARY CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMAGINE PRIMARY CARE, PC
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:
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:
1184380099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 BRIGGS LANE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02738-1681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
774-264-0932
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 FAUNCE CORNER RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DARTMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02747-1271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
774-264-0932
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PODKOWA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
774-264-0932

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1932373552 . This is a "NPI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1285621300 . This is a "NPI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1457808024 . This is a "NPI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1750361713 . This is a "NPI" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".