1396780904 NPI number — HERBERT S PLOVNICK M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396780904 NPI number — HERBERT S PLOVNICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PLOVNICK
Provider First Name:
HERBERT
Provider Middle Name:
S
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:
1396780904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 MILK ST
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT - 9TH FLOOR
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02109-4806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-559-8374
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 CITY HALL MALL
Provider Second Line Business Practice Location Address:
INTERNAL MEDICINE
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-4754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-306-5345
Provider Business Practice Location Address Fax Number:
781-306-5015
Provider Enumeration Date:
06/18/2006

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: 207R00000X , with the licence number:  38333 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RE0101X , with the licence number: 38333 , 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: M09787 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 705817 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0119873 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0015311 . This is a "NEIGHBRHOOD HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: V534 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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