1932105095 NPI number — DR. CHARLES WILLIAM CONNOLLY DPM

Table of content: DR. CHARLES WILLIAM CONNOLLY DPM (NPI 1932105095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932105095 NPI number — DR. CHARLES WILLIAM CONNOLLY DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNOLLY
Provider First Name:
CHARLES
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1932105095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 COLLEGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERVILLE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02144-1919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-593-1700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOMERVILLE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02144-1919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-776-2500
Provider Business Practice Location Address Fax Number:
617-776-3850
Provider Enumeration Date:
06/23/2005

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: 213E00000X , with the licence number:  1784 , 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: Y70860 . This is a "BLUE SHIELD OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 709158 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0361968 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33386 . This is a "HARVARD PILGRIM HEALTH CA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2700037 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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