1376023671 NPI number — GANNA DOLGOPOLOVA

Table of content: GANNA DOLGOPOLOVA (NPI 1376023671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376023671 NPI number — GANNA DOLGOPOLOVA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOLGOPOLOVA
Provider First Name:
GANNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1376023671
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/28/2021
NPI Reactivation Date:
03/21/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27777 INKSTER RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-5312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
857-498-0814
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 SCHOOL ST RM 325
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02108-4209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
857-498-0814
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2018

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: 103K00000X , with the licence number:  3943-MH-B1 , 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: 110026265E , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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