1508964230 NPI number — DERMATOLOGY ASSOCIATES OF CONCORD INC

Table of content: (NPI 1508964230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508964230 NPI number — DERMATOLOGY ASSOCIATES OF CONCORD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY ASSOCIATES OF CONCORD INC
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:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1508964230
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 BAKER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01742-2189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-369-9023
Provider Business Mailing Address Fax Number:
978-371-9675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 BAKER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01742-2189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-369-9023
Provider Business Practice Location Address Fax Number:
978-371-9675
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HADLEY
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-369-9023

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M11607 . This is a "BLUE S HIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9703713 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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