1710100698 NPI number — MARY JANE ROGALSKI RD, LDN

Table of content: MARY JANE ROGALSKI RD, LDN (NPI 1710100698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710100698 NPI number — MARY JANE ROGALSKI RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROGALSKI
Provider First Name:
MARY JANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN
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:
1710100698
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:
32 WELLS PARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURBRIDGE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01566-1316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-347-7650
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
759 CHESTNUT ST
Provider Second Line Business Practice Location Address:
BAYSTATE MEDICAL CENTER C1340
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01199-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-794-4954
Provider Business Practice Location Address Fax Number:
413-794-4949
Provider Enumeration Date:
04/10/2007

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: 133V00000X , with the licence number:  507 , 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)





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