1336341502 NPI number — DANIEL RUTRICK, MD, PC

Table of content: (NPI 1336341502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336341502 NPI number — DANIEL RUTRICK, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANIEL RUTRICK, MD, PC
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:
1336341502
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:
617 BROADWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02149-3712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-387-2220
Provider Business Mailing Address Fax Number:
617-394-0538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
617 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02149-3712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-387-2220
Provider Business Practice Location Address Fax Number:
617-394-0538
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUTRICK
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
617-387-2220

Provider Taxonomy Codes

  • Taxonomy code: 103TP0016X , with the licence number:  36462 , 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: M13835 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 036462 . This is a "TUFTS GROUP NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 500019 . This is a "TUFTS PSYCHOLOGIST NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 500064 . This is a "TUFTS CERTIFIED NURSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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