1801885256 NPI number — PARKLAND PHYSICIAN SERVICES, INC

Table of content: (NPI 1801885256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801885256 NPI number — PARKLAND PHYSICIAN SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKLAND PHYSICIAN SERVICES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DBA DR. ALPHONSE J. BALUTA, JR.
Provider Other Organization Name Type Code:
3
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:
1801885256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
184 MAMMOTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDONDERRY
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03053-3254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-434-9666
Provider Business Mailing Address Fax Number:
603-425-2973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
184 MAMMOTH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDONDERRY
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03053-3254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-434-9666
Provider Business Practice Location Address Fax Number:
603-425-2973
Provider Enumeration Date:
10/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WASHINGTON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
703-650-2907

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30214303 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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