1962652990 NPI number — MERRIMACK VALLEY PAIN MANAGEMENT ASSOCIATES, P.C.

Table of content: (NPI 1962652990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962652990 NPI number — MERRIMACK VALLEY PAIN MANAGEMENT ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRIMACK VALLEY PAIN MANAGEMENT ASSOCIATES, P.C.
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:
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:
1962652990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 MERRIMACK ST STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01843-1780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-685-2455
Provider Business Mailing Address Fax Number:
978-685-2459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 MERRIMACK ST STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01843-1780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-685-2455
Provider Business Practice Location Address Fax Number:
978-685-2459
Provider Enumeration Date:
09/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RUSTUM
Authorized Official First Name:
RAMI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-685-2455

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  213741 , 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: 1962652990 . This is a "TRICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 614350100 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 614350100 . This is a "ACS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9744801 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA132832 . This is a "HEALTHCARE VALUE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 30217445 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA132832 . This is a "HEALTH PLANS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M19676 . This is a "BC/BS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA132832 . This is a "HARVARD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1881694180 . This is a "BMC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1881694180 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1962652990 . This is a "GIC UNICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9111315 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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