1871147264 NPI number — DR. RONALD WILSON MAKARUTSA RN

Table of content: DR. RONALD WILSON MAKARUTSA RN (NPI 1871147264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871147264 NPI number — DR. RONALD WILSON MAKARUTSA RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAKARUTSA
Provider First Name:
RONALD
Provider Middle Name:
WILSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
M

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:
1871147264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 MERRIMAC WAY UNIT H
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYNGSBORO
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01879-2760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-853-0284
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
295 VARNUM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOWELL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01854-2134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-937-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2019

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: 163W00000X , with the licence number:  132742 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: 60919611 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WG0100X , with the licence number: 266267 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: 266267 , 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)





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