1780673558 NPI number — LEO JOSEPH TROY JR. MD

Table of content: LEO JOSEPH TROY JR. MD (NPI 1780673558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780673558 NPI number — LEO JOSEPH TROY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TROY
Provider First Name:
LEO
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
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:
1780673558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 GUEST ST STE 225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02135-2065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-491-6766
Provider Business Mailing Address Fax Number:
617-491-2552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MOUNT AUBURN ST
Provider Second Line Business Practice Location Address:
STE 505
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02138-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-491-6766
Provider Business Practice Location Address Fax Number:
617-491-2552
Provider Enumeration Date:
10/14/2005

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: 207X00000X , with the licence number:  59881 , 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: 3046435 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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