1346261302 NPI number — GORDON JURIC M.D.

Table of content: GORDON JURIC M.D. (NPI 1346261302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346261302 NPI number — GORDON JURIC M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JURIC
Provider First Name:
GORDON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1346261302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
163 LIBBEY INDUSTRIAL PKWY
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
WEYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02189-3137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-337-4224
Provider Business Mailing Address Fax Number:
781-335-0429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
163 LIBBEY INDUSTRIAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
WEYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02189-3137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-337-4224
Provider Business Practice Location Address Fax Number:
781-335-0429
Provider Enumeration Date:
07/22/2006

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: 207L00000X , with the licence number:  75606 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: 75606 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: F26097 . This is a "TRICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 275178 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3092305 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J12427 . This is a "BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 075605 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 050049692 . This is a "PALMETTO GBA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 364770 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3092305 . This is a "HEALTHY START" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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