1205829579 NPI number — NEW ENGLAND NEUROLOGICAL

Table of content: (NPI 1205829579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205829579 NPI number — NEW ENGLAND NEUROLOGICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW ENGLAND NEUROLOGICAL
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:
1205829579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
354 MERRIMACK ST
Provider Second Line Business Mailing Address:
BLDG. 1
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01843-1754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-687-2321
Provider Business Mailing Address Fax Number:
978-685-7265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 MERRIMACK ST
Provider Second Line Business Practice Location Address:
BLDG. 1
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01843-1754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-687-2321
Provider Business Practice Location Address Fax Number:
978-685-7265
Provider Enumeration Date:
08/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
978-687-2321

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084N0402X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 97497 . This is a "USHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 99903151 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 701417 . This is a "THP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M11158 . This is a "BCBSMA PHYSICIAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W10119 . This is a "BCBSMA PSYCHOLOGIST" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9711694 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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