1639217276 NPI number — DR. SUZANNE MATTOS GRONDIN DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639217276 NPI number — DR. SUZANNE MATTOS GRONDIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRONDIN
Provider First Name:
SUZANNE
Provider Middle Name:
MATTOS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTOS
Provider Other First Name:
SUZANNE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639217276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
123 SUMMER ST
Provider Second Line Business Mailing Address:
SUITE 550
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01608-1216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-363-6868
Provider Business Mailing Address Fax Number:
508-363-6866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 SUMMER ST
Provider Second Line Business Practice Location Address:
SUITE 550
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01608-1216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-363-6868
Provider Business Practice Location Address Fax Number:
508-363-6866
Provider Enumeration Date:
02/04/2007

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: 213E00000X , with the licence number:  2319 , 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: 0711772 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121815 . This is a "FALLON HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y71137 . This is a "BLUE SHEILD OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 466883 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA84858 . This is a "HARVARD PILGRIM HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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