1629043625 NPI number — DR. PETER JOHN DRENNAN D.O.

Table of content: DR. PETER JOHN DRENNAN D.O. (NPI 1629043625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629043625 NPI number — DR. PETER JOHN DRENNAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRENNAN
Provider First Name:
PETER
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1629043625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2150 MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-739-5676
Provider Business Mailing Address Fax Number:
413-733-5860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 ENFIELD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-741-6058
Provider Business Practice Location Address Fax Number:
860-253-9326
Provider Enumeration Date:
02/22/2006

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: 207R00000X , with the licence number:  64560 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 54104 , 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: 110051774A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003116242 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64994127 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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