1477697076 NPI number — MR. STEPHEN LEBLANC

Table of content: MR. STEPHEN LEBLANC (NPI 1477697076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477697076 NPI number — MR. STEPHEN LEBLANC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEBLANC
Provider First Name:
STEPHEN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1477697076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
173 GROVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605-1715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-791-8740
Provider Business Mailing Address Fax Number:
508-752-3716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
173 GROVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01605-1715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-791-8740
Provider Business Practice Location Address Fax Number:
508-752-3716
Provider Enumeration Date:
02/16/2007

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: 225100000X , with the licence number:  10258 , 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: 626330 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 981075 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 729323 . This is a "CONNECTICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 459035 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1477697076 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9645094 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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