1487415741 NPI number — TUFTS MEDICINE SHIELDS PET CT LLC

Table of content: (NPI 1487415741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487415741 NPI number — TUFTS MEDICINE SHIELDS PET CT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TUFTS MEDICINE SHIELDS PET CT LLC
Provider Last Name:
Provider First Name:
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Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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NPI Number Information

NPI Number:
1487415741
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 CONGRESS ST STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02169-0928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
888 MAIN ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAKEFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01880-4080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-765-3063
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2024

Additional Information

Authorized Official

Authorized Official Last Name:
HORSFALL
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official Telephone Number:
800-258-4674

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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