1922367168 NPI number — LONGWOOD ACADEMIC PHYSICIANS, LLC

Table of content: (NPI 1922367168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922367168 NPI number — LONGWOOD ACADEMIC PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGWOOD ACADEMIC PHYSICIANS, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1922367168
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
198 GROTON RD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
AYER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01432-1177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-772-3793
Provider Business Mailing Address Fax Number:
978-772-3797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
198 GROTON RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
AYER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01432-1177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-772-3793
Provider Business Practice Location Address Fax Number:
978-772-3797
Provider Enumeration Date:
05/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DIGIORGIO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF NETWORK OPERATIONS
Authorized Official Telephone Number:
617-632-7373

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  76993 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0001X , with the licence number: 76993 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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