1699754507 NPI number — DR. LESLIE A SHINOBU MD PHD

Table of content: DR. LESLIE A SHINOBU MD PHD (NPI 1699754507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699754507 NPI number — DR. LESLIE A SHINOBU MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHINOBU
Provider First Name:
LESLIE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1699754507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9142
Provider Second Line Business Mailing Address:
MASS GENERAL PHYSICIAN ORGANIZATION
Provider Business Mailing Address City Name:
CHARLESTOWN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02129-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-724-0287
Provider Business Mailing Address Fax Number:
617-726-2894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 PARKMAN ST
Provider Second Line Business Practice Location Address:
WAC 830 NEUROLOGY ASSOCIATES
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-726-5532
Provider Business Practice Location Address Fax Number:
617-726-6991
Provider Enumeration Date:
01/10/2006

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: 2084N0400X , with the licence number:  78256 , 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: J16437 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 078256 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3148289 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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