1154416949 NPI number — DR. JAY ALLAN BERNASCONI DPT, OCS

Table of content: DR. JAY ALLAN BERNASCONI DPT, OCS (NPI 1154416949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154416949 NPI number — DR. JAY ALLAN BERNASCONI DPT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNASCONI
Provider First Name:
JAY
Provider Middle Name:
ALLAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT, OCS
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:
1154416949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 TOTMAN ST
Provider Second Line Business Mailing Address:
FIRST FLOOR
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02169-7564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-770-4167
Provider Business Mailing Address Fax Number:
617-770-0971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 TOTMAN ST
Provider Second Line Business Practice Location Address:
FIRST FLOOR
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02169-7564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-770-4167
Provider Business Practice Location Address Fax Number:
617-770-0971
Provider Enumeration Date:
10/04/2006

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:  5087 , 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: BEY65909 . This is a "BC/BS OF MA." identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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