1477614196 NPI number — ROSTISLAVA KANYUK-STOUPNITSKA MD

Table of content: ROSTISLAVA KANYUK-STOUPNITSKA MD (NPI 1477614196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477614196 NPI number — ROSTISLAVA KANYUK-STOUPNITSKA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KANYUK-STOUPNITSKA
Provider First Name:
ROSTISLAVA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1477614196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9132
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLINE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-296-2302
Provider Business Mailing Address Fax Number:
978-296-2304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 HAVERHILL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-296-2302
Provider Business Practice Location Address Fax Number:
978-296-2304
Provider Enumeration Date:
12/13/2006

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:  38662 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 233627 , 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: 129960 . This is a "FALLON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1477614196 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2142171 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41844 . This is a "NHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1477614196 . This is a "BMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30207632 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: J42642 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8961939 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA97507 . This is a "HPHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 459069 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 95855401 . This is a "NETWORK HEALTH" identifier . This identifiers is of the category "OTHER".




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