1649392416 NPI number — PRIMARY CARE NORTH PC

Table of content: (NPI 1649392416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649392416 NPI number — PRIMARY CARE NORTH PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY CARE NORTH PC
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:
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:
1649392416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 BOSTON ST
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
LYNN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01904-3137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-595-9581
Provider Business Mailing Address Fax Number:
781-595-9628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 BOSTON ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
LYNN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01904-3137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-595-9581
Provider Business Practice Location Address Fax Number:
781-595-9628
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NALESNIK
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
781-595-9581

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  53680 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: B1002301 . This is a "CIGNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 703505 . This is a "TUFTS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 80744 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9705121 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: J04507 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9037 . This is a "US HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 65494 . This is a "HPHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0400048 . This is a "UNITED" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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