1962418525 NPI number — MRS. JENNIFER M MADDOCKS MSPT

Table of content: MRS. JENNIFER M MADDOCKS MSPT (NPI 1962418525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962418525 NPI number — MRS. JENNIFER M MADDOCKS MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADDOCKS
Provider First Name:
JENNIFER
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MICHAUD
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962418525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3701 NW CARY PARKWAY
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
CARY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-388-0111
Provider Business Mailing Address Fax Number:
919-388-8668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3701 NW CARY PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-388-0111
Provider Business Practice Location Address Fax Number:
919-388-8668
Provider Enumeration Date:
08/01/2006

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: 225100000X , with the licence number:  8277 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3210671 . This is a "AETNA HMO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6698131 . This is a "GHI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 836264 . This is a "UHC ACN MPN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5004734 . This is a "AETNA PPO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7360555 . This is a "UHC ACN MPN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 079C2 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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