1730145533 NPI number — JENNIFER J AVERILL MOFFITT CNM

Table of content: JENNIFER J AVERILL MOFFITT CNM (NPI 1730145533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730145533 NPI number — JENNIFER J AVERILL MOFFITT CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVERILL MOFFITT
Provider First Name:
JENNIFER
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AVERILL
Provider Other First Name:
JENNIFFER
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730145533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 QUEEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01610-2473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-860-7700
Provider Business Mailing Address Fax Number:
508-860-7929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 QUEEN ST
Provider Second Line Business Practice Location Address:
FAMILY HEALTH CENTER OF WORCESTER, INC.
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01610-2473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-860-7700
Provider Business Practice Location Address Fax Number:
508-860-7929
Provider Enumeration Date:
04/21/2006

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: 176B00000X , with the licence number:  257370 , 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: 1300709 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y10141 . This is a "MEDICARE GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: CN0334 . This is a "BLUE SHIELD NUMBER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".