1780707901 NPI number — AIMEE KOREN GRAY PICKETT OD

Table of content: AIMEE KOREN GRAY PICKETT OD (NPI 1780707901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780707901 NPI number — AIMEE KOREN GRAY PICKETT OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY PICKETT
Provider First Name:
AIMEE
Provider Middle Name:
KOREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAY
Provider Other First Name:
AIMEE
Provider Other Middle Name:
KOREN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780707901
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 INDUSTRIAL PARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-4884
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-746-8600
Provider Business Mailing Address Fax Number:
508-747-0824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 INDUSTRIAL PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02360-4884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-746-8600
Provider Business Practice Location Address Fax Number:
508-747-0824
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: 152W00000X , with the licence number:  4901004182 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4197 , 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: 900E06513 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA227707 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 110014827A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110955 . This is a "EYE MED" identifier . This identifiers is of the category "OTHER".
  • Identifier: W1736901 . This is a "MEDICARE, NHIC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 7368965 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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