1710161773 NPI number — PETER J KAZANOVICZ

Table of content: (NPI 1710161773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710161773 NPI number — PETER J KAZANOVICZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER J KAZANOVICZ
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:
6
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:
1710161773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
169 S RIVER RD
Provider Second Line Business Mailing Address:
UNIT 14A
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03110-6971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-622-5200
Provider Business Mailing Address Fax Number:
603-644-2354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1685 CONGRESS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04102-2776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-772-1467
Provider Business Practice Location Address Fax Number:
603-644-2354
Provider Enumeration Date:
12/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KAZANOVICZ
Authorized Official First Name:
PETER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
BOARD CERTIFIED OCULARIST/OWNER
Authorized Official Telephone Number:
603-622-5200

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 141840000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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