1578831574 NPI number — LADAN MIREMADI THOMPSON

Table of content: LADAN MIREMADI THOMPSON (NPI 1578831574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578831574 NPI number — LADAN MIREMADI THOMPSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
LADAN
Provider Middle Name:
MIREMADI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1578831574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 DARTMOUTH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALDEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-306-4820
Provider Business Mailing Address Fax Number:
781-393-6554

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
282 CENTRAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ACTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01720-4790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-472-0224
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2011

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1303414 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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