1649346925 NPI number — SUETTA TENNEY MD

Table of content: SUETTA TENNEY MD (NPI 1649346925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649346925 NPI number — SUETTA TENNEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TENNEY
Provider First Name:
SUETTA
Provider Middle Name:
Provider Name Prefix Text:
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:
1649346925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 42738
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21284-2738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-494-7607
Provider Business Mailing Address Fax Number:
610-925-7387

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GENESIS HEALTH CARE WINWARD GARDENS NURSING CENTER
Provider Second Line Business Practice Location Address:
105 MECHANIC STREET
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-236-4197
Provider Business Practice Location Address Fax Number:
207-230-0563
Provider Enumeration Date:
11/28/2006

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:  MD22576 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 71345 , 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: 3002764 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69626 . This is a "HARVARD PILGRAM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 71345 . This is a "MASS LICENSE #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 712914 . This is a "TUETS HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0701800 . This is a "BC BS ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4978 . This is a "FALLON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110229385 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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