1710989322 NPI number — SAMUEL P DONEGAN MD

Table of content: SAMUEL P DONEGAN MD (NPI 1710989322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710989322 NPI number — SAMUEL P DONEGAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONEGAN
Provider First Name:
SAMUEL
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1710989322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 MASSACHUSETTS AVENUE
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 OAK STREET
Provider Second Line Business Practice Location Address:
SUITE 223E
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-427-2222
Provider Business Practice Location Address Fax Number:
508-897-4773
Provider Enumeration Date:
08/12/2005

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: 207V00000X , with the licence number:  D0068818 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 56194 , 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: 152599ZEZT . This is a "MEDICARE PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 022452900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 165767 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 110043227A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 950201 . This is a "CAREFIRST RENDERING NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: Q818-0019 . This is a "CAREFIRST" identifier . This identifiers is of the category "OTHER".




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