1558404814 NPI number — MS. MARGARITA G BURDETSKY PAC MS

Table of content: MS. MARGARITA G BURDETSKY PAC MS (NPI 1558404814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558404814 NPI number — MS. MARGARITA G BURDETSKY PAC MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURDETSKY
Provider First Name:
MARGARITA
Provider Middle Name:
G
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC MS
Provider Gender Code:
F

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:
1558404814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CHA-EVERETT FAMILY HEALTH CENTER
Provider Second Line Business Mailing Address:
391 BROADWAY
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-389-0045
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 BROADWAY STE 204
Provider Second Line Business Practice Location Address:
PROHEALTH INTAGRATED MEDICAL
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02149-3471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-389-0045
Provider Business Practice Location Address Fax Number:
617-389-1619
Provider Enumeration Date:
02/15/2007

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: 363A00000X , with the licence number:  PA5063 , 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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