1184714115 NPI number — DR. WYNN A PERLICK DPM

Table of content: DR. WYNN A PERLICK DPM (NPI 1184714115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184714115 NPI number — DR. WYNN A PERLICK DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERLICK
Provider First Name:
WYNN
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

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:
1184714115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 WILLARD ST
Provider Second Line Business Mailing Address:
SUITE 2F
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02169-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-773-2313
Provider Business Mailing Address Fax Number:
617-328-3861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 WILLARD ST
Provider Second Line Business Practice Location Address:
SUITE 2F
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02169-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-773-2313
Provider Business Practice Location Address Fax Number:
617-328-3861
Provider Enumeration Date:
10/13/2006

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: 213E00000X , with the licence number:  2053 , 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: 042297845 . This is a "GREAT WEST HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "PHCS/MULTI-PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "GIC/UNICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002053 . This is a "TUFTS MEDICARE PREFERRED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1215062 . This is a "FALLON" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y71014 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043376631 . This is a "GIC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 043376631 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 043376631 . This is a "PRUDENTIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33917 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002053 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0620074 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 27 00004 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 334257 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "HCVM/FIRST HEALTH/COVENTY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5297190 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: Y77182 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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