1992973986 NPI number — GREGORY T BODRIE OD

Table of content: (NPI 1992973986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992973986 NPI number — GREGORY T BODRIE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREGORY T BODRIE OD
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:
1992973986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 532
Provider Second Line Business Mailing Address:
66 PLEASANT STREET
Provider Business Mailing Address City Name:
SAGAMORE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02561-0532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-888-2020
Provider Business Mailing Address Fax Number:
508-888-4423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 PLEASANT ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAGAMORE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02561-0532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-888-2020
Provider Business Practice Location Address Fax Number:
508-888-4423
Provider Enumeration Date:
02/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BODRIE
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
TAYLOR
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
508-888-2020

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  2646 , 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: 0332003 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: W15268 . This is a "BLUE CROSS / BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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