1538373295 NPI number — HARVARD VANGUARD MEDICAL ASSOCIATES, INC

Table of content: (NPI 1538373295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538373295 NPI number — HARVARD VANGUARD MEDICAL ASSOCIATES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HARVARD VANGUARD MEDICAL ASSOCIATES, 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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538373295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 GROVE STREET
Provider Second Line Business Mailing Address:
SUITE 3-300
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-559-8374
Provider Business Mailing Address Fax Number:
617-421-3487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 ESSEX CENTER DR
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
PEABODY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01960-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-532-2800
Provider Business Practice Location Address Fax Number:
978-977-4226
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURNES
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
617-559-8393

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0029501 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M18223 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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