1336117316 NPI number — RAYNHAM TAUNTON PEDIATRICS

Table of content: (NPI 1336117316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336117316 NPI number — RAYNHAM TAUNTON PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYNHAM TAUNTON PEDIATRICS
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:
1336117316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
876 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAYNHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02767-1797
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-824-9500
Provider Business Mailing Address Fax Number:
508-824-9507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
876 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAYNHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02767-1797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-824-9500
Provider Business Practice Location Address Fax Number:
508-824-9507
Provider Enumeration Date:
03/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERLIN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
508-824-9500

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  52899 , 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: J03588 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9702130 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 052899 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2145974 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: B10358301 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 12-01645 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 200584 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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