1578710653 NPI number — STEWARD PET IMAGING, L.L.C.

Table of content: (NPI 1578710653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578710653 NPI number — STEWARD PET IMAGING, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEWARD PET IMAGING, L.L.C.
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:
6
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:
1578710653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWOOD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02062-3487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-877-8455
Provider Business Mailing Address Fax Number:
866-927-0079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 DORCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORCHESTER CENTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02124-5615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-877-8455
Provider Business Practice Location Address Fax Number:
866-927-0079
Provider Enumeration Date:
08/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GUYON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
617-789-5047

Provider Taxonomy Codes

  • Taxonomy code: 261QR0208X , with the licence number:  4NNJ , 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: 110073236E , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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