1790887438 NPI number — MS. ELISE BLAIR SHEVENELL MS, PT

Table of content: MS. ELISE BLAIR SHEVENELL MS, PT (NPI 1790887438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790887438 NPI number — MS. ELISE BLAIR SHEVENELL MS, PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEVENELL
Provider First Name:
ELISE
Provider Middle Name:
BLAIR
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, PT
Provider Gender Code:
F

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:
1790887438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 COURT SQ
Provider Second Line Business Mailing Address:
SUITE 345
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02108-2503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-742-4897
Provider Business Mailing Address Fax Number:
617-742-4899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 COURT SQ
Provider Second Line Business Practice Location Address:
SUITE 345
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02108-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-742-4897
Provider Business Practice Location Address Fax Number:
617-742-4899
Provider Enumeration Date:
09/02/2006

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: 225100000X , with the licence number:  3804 , 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: Y65801 . This is a "BLUE CROSS - BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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