1558414060 NPI number — DR. ELIZABETH MAINZER GAGNON PHD

Table of content: DR. ELIZABETH MAINZER GAGNON PHD (NPI 1558414060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558414060 NPI number — DR. ELIZABETH MAINZER GAGNON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAGNON
Provider First Name:
ELIZABETH
Provider Middle Name:
MAINZER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1558414060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 FRANKLIN ST
Provider Second Line Business Mailing Address:
SUITE 809
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02110-1510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-451-0055
Provider Business Mailing Address Fax Number:
617-451-0055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 FRANKLIN ST
Provider Second Line Business Practice Location Address:
SUITE 809
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02110-1510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-451-0055
Provider Business Practice Location Address Fax Number:
617-451-0055
Provider Enumeration Date:
01/19/2007

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: 103TC0700X , with the licence number:  8186 , 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)

  • Identifier: W06313 . 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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