1568549772 NPI number — MEDICAL ASSOCIATES OF SAUGUS PC

Table of content: (NPI 1568549772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568549772 NPI number — MEDICAL ASSOCIATES OF SAUGUS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL ASSOCIATES OF SAUGUS PC
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:
1568549772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ONE ROOSEVELT AVENUE SUITE 204
Provider Second Line Business Mailing Address:
MEDICAL ASSOCIATES OF SAUGUS
Provider Business Mailing Address City Name:
PEABODY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-536-7778
Provider Business Mailing Address Fax Number:
978-536-2998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE ROOSEVELT AVENUE SUITE 204
Provider Second Line Business Practice Location Address:
MEDICAL ASSOCIATES OF SAUGUS
Provider Business Practice Location Address City Name:
PEABODY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-536-7778
Provider Business Practice Location Address Fax Number:
978-536-2998
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GANDOLFO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-536-7778

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9701133 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 685660 . This is a "TOFTS HEALTH PLANS MA" identifier . This identifiers is of the category "OTHER".
  • Identifier: M17573 . This is a "BLUE SHIELD OF MA" identifier . This identifiers is of the category "OTHER".




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