1235273681 NPI number — DR. KELLEY L GLASS AU.D

Table of content: DR. KELLEY L GLASS AU.D (NPI 1235273681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235273681 NPI number — DR. KELLEY L GLASS AU.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLASS
Provider First Name:
KELLEY
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D
Provider Gender Code:
F

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:
1235273681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 PROSPECT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SWAMPSCOTT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01907-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
339-440-4122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
79 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01970-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-741-1284
Provider Business Practice Location Address Fax Number:
978-745-0203
Provider Enumeration Date:
02/19/2007

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: 237600000X , with the licence number:  511 , 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: 5104050 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AD0076 . This is a "BLUE SHIELD PROVIDER NUMB" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 511 . This is a "MASS STATE LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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