1770679730 NPI number — DR. JAMES FX KENEALY MD

Table of content: CAYCEY WAMEGO RN (NPI 1992491963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770679730 NPI number — DR. JAMES FX KENEALY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENEALY
Provider First Name:
JAMES
Provider Middle Name:
FX
Provider Name Prefix Text:
DR.
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:
1770679730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 PLANTATION 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:
01605-2038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-368-3103
Provider Business Mailing Address Fax Number:
508-368-3104

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 SUMMER ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01608-1216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-368-3103
Provider Business Practice Location Address Fax Number:
508-368-3104
Provider Enumeration Date:
10/05/2006

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: 174400000X , with the licence number:  74266 , 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: 040004967 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 54857 . This is a "FALLON DIRECT/SELECT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 61683 . This is a "USHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 074266 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1000006 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 19143 . This is a "HARVARD PILGRIM MWMC IPA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 19551 . This is a "HARVARD PILGRIM MILF IPA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3087514 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0017055 . This is a "NEIGHBORHOOD HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 23504 . This is a "CHILDRENS MEDICAL SEC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J11142 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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