1154420008 NPI number — PHILIP S. ELLERIN, MD,PC

Table of content: (NPI 1154420008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154420008 NPI number — PHILIP S. ELLERIN, MD,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHILIP S. ELLERIN, MD,PC
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:
1154420008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 WILLIS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01940-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-334-4168
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
172 CAMBRIDGE ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01803-2984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-272-7022
Provider Business Practice Location Address Fax Number:
781-272-8786
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELLERIN
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
781-272-7022

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 709176 . This is a "GROUP TUFTS PROV #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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