1477671055 NPI number — ANTHONY G MONCTON

Table of content: (NPI 1477671055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477671055 NPI number — ANTHONY G MONCTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANTHONY G MONCTON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1477671055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 SOUTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01581-1619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-366-6630
Provider Business Mailing Address Fax Number:
508-366-6640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01581-1619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-366-6630
Provider Business Practice Location Address Fax Number:
508-366-6640
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONCTON
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
GABOR
Authorized Official Title or Position:
CEO OWNER
Authorized Official Telephone Number:
508-366-6630

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1792 , 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: Y39800 . This is a "BCBS GROUP NO." identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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