1235104050 NPI number — MS. NANCY RUTH CETLIN EDD

Table of content: MS. NANCY RUTH CETLIN EDD (NPI 1235104050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235104050 NPI number — MS. NANCY RUTH CETLIN EDD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CETLIN
Provider First Name:
NANCY
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
EDD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILTON
Provider Other First Name:
NANCY
Provider Other Middle Name:
CETLIN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
EDD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1235104050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 BROOKS ST
Provider Second Line Business Mailing Address:
UNIT 1
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-254-0284
Provider Business Mailing Address Fax Number:
617-782-6764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
264 BEACON ST
Provider Second Line Business Practice Location Address:
FOURTH FLOOR
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-267-5433
Provider Business Practice Location Address Fax Number:
617-782-6764
Provider Enumeration Date:
02/23/2006

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: 103TC0700X , with the licence number:  3514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 6301002901 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0001020601 . This is a "MANAGED HEALTH NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: VD6841 . This is a "EMPIRE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6883946 . This is a "VALUE/OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: A002908 . This is a "VAL/H" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0012255000 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: W03627 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 739159 . This is a "TUFTS HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: A002908 . This is a "VALUE" identifier . This identifiers is of the category "OTHER".




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