1942209721 NPI number — 312 MILLBURY AVENUE OPERATING COMPANY, LLC

Table of content: MARIAN A. FEDAK M.D. (NPI 1245313683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942209721 NPI number — 312 MILLBURY AVENUE OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
312 MILLBURY AVENUE OPERATING COMPANY, 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:
1942209721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
312 MILLBURY AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILLBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-793-0088
Provider Business Mailing Address Fax Number:
508-793-1671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 MILLBURY AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILLBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-793-0088
Provider Business Practice Location Address Fax Number:
508-793-1671
Provider Enumeration Date:
07/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VAZQUEZ
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, SPECIAL PROJECTS
Authorized Official Telephone Number:
978-930-6051

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , 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: 0926817 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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