1861155426 NPI number — GRACE ROBERTSON

Table of content: GRACE ROBERTSON (NPI 1861155426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861155426 NPI number — GRACE ROBERTSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTSON
Provider First Name:
GRACE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1861155426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 ELM ST STE 106H
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03101-1828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-600-1033
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 MIDDLESEX ST STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH CHELMSFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01863-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-600-1033
Provider Business Practice Location Address Fax Number:
978-428-5811
Provider Enumeration Date:
10/20/2021

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: 363LP0808X , with the licence number:  RN2282655 , 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: 000000 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000 . This is a "OPTUM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 000000 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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