1619035086 NPI number — DR. BONNIE L MATHEWS MD

Table of content: DR. BONNIE L MATHEWS MD (NPI 1619035086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619035086 NPI number — DR. BONNIE L MATHEWS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHEWS
Provider First Name:
BONNIE
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1619035086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415348
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-5348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-225-8885
Provider Business Mailing Address Fax Number:
508-334-1977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 LAKE AVE N
Provider Second Line Business Practice Location Address:
PEDIATRIC EMERGENCY MEDICINE
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01655-0002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
774-442-2599
Provider Business Practice Location Address Fax Number:
774-442-2510
Provider Enumeration Date:
12/05/2006

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: 2080P0204X , with the licence number:  223848 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 223848 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2132524 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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