1821055773 NPI number — LISA J PUGH NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821055773 NPI number — LISA J PUGH NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUGH
Provider First Name:
LISA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1821055773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
999 BROADWAY STE 101-I
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUGUS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01906-4521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-832-0035
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
999 BROADWAY STE 101-I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAUGUS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01906-4521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-832-0035
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2006

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: 363L00000X , with the licence number:  197514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 197514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 197514 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 197514 , 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: 39158 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0374971 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP3032 . This is a "BLUE CROSS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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