1548483183 NPI number — BROOKE RUTLEDGE SECKEL M.D.

Table of content: BROOKE RUTLEDGE SECKEL M.D. (NPI 1548483183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548483183 NPI number — BROOKE RUTLEDGE SECKEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SECKEL
Provider First Name:
BROOKE
Provider Middle Name:
RUTLEDGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1548483183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 FAIRHAVEN ROAD
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-369-8233
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 COMMONWEALTH AVE
Provider Second Line Business Practice Location Address:
317
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02116-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-455-2859
Provider Business Practice Location Address Fax Number:
866-743-7213
Provider Enumeration Date:
04/11/2007

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: 208200000X , with the licence number:  34084 , 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)





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