1356352413 NPI number — JACQUELYN R MCKEAN MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356352413 NPI number — JACQUELYN R MCKEAN MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MCKEAN

Provider First Name:

JACQUELYN

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1356352413

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/30/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

26 QUEEN ST

Provider Second Line Business Mailing Address:

MEDICAL

Provider Business Mailing Address City Name:

WORCESTER

Provider Business Mailing Address State Name:

MA

Provider Business Mailing Address Postal Code:

01610-2473

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

508-860-7700

Provider Business Mailing Address Fax Number:

508-860-7990

Provider First Line Business Practice Location Address:

81 RESERVOIR DR

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ATHOL

Provider Business Practice Location Address State Name:

MA

Provider Business Practice Location Address Postal Code:

01331-4901

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

978-248-5135

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

08/11/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  206096 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0035749 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 1300709 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
• Identifier: 97679702 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 042485308 . This is a "NETWORK HEALTH-GROUP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 49201 . This is a "FALLON SELECT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 0006767 . This is a "NHP-GROUP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: J23197 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: Y10141 . This is a "BCBS-GROUP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 81738 . This is a "CMSP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: 2437886 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
• Identifier: AA25557 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".