| NPI |
1174583512 |
|
| Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Employer Identification Number EIN |
|
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
| Provider Organization Name Legal Business Name |
JOHN R KASHMANIAN DMD INC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider First Line Business Practice Location Address |
55 EVERETT ST |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider Business Practice Location Address City Name |
SOUTHBRIDGE |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
MA |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address Postal Code |
01550 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Telephone Number |
5087650099 |
The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number |
5087650091 |
The fax number associated with the location
address of the provider being identified. |
| Provider Enumeration Date |
3/27/2006 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
8/22/2020 |
The date that a record was last updated or changed. |
| Authorized Official Last Name |
KASHMANIAN |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official First Name |
JOHN |
The first name of the authorized official. |
| Authorized Official Middle Name |
R |
The middle name of the authorized official. |
| Authorized Official Title or Position |
PRESIDENT |
The title or position of the authorized official. |
| Authorized Official Telephone Number |
5087650099 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
204E00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider License Number 1 |
0016765 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 1 |
MA |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Other Provider Identifier 1 |
1082 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 1 |
MA |
|
| Other Provider Identifier Issuer 1 |
DELTA DENTAL MA |
|
| Other Provider Identifier 2 |
368390 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 2 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 2 |
CIGNA |
|
| Other Provider Identifier 3 |
0273147 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 3 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 3 |
MA |
|
| Other Provider Identifier 4 |
12207 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 4 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 4 |
FALLON COMMUNITY HEALTH P |
|
| Other Provider Identifier 5 |
792734 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 5 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 5 |
UNITED CONCORDIA |
|
| Other Provider Identifier 6 |
16531 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 6 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 6 |
HARVARD PILGRIM HEALTHCAR |
|
| Other Provider Identifier 7 |
983782 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 7 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 7 |
MA |
|
| Other Provider Identifier Issuer 7 |
NETWORK HEALTH |
|
| Other Provider Identifier 8 |
X06293 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 8 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 8 |
MA |
|
| Other Provider Identifier Issuer 8 |
BCBS MEDICAL AND DENTAL |
|
| Other Provider Identifier 9 |
754041 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 9 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 9 |
TUFTS HEALTH PLAN |
|
| Is Organization Subpart |
N |
|
| Authorized Official Credential Text |
DMD |
|
| Healthcare Provider Taxonomy Group 1 |
193200000X MULTI-SPECIALTY GROUP |
|