Basic Information
Provider Information | |||||||||
NPI: | 1073617353 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDINBURG CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 BURLINGTON RD | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 017301406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7817615064 | ||||||||
FaxNumber: | 7812757205 | ||||||||
Practice Location | |||||||||
Address1: | 205 BURLINGTON RD | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 017301406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7817615208 | ||||||||
FaxNumber: | 7812757205 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2006 | ||||||||
LastUpdateDate: | 06/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAGAN | ||||||||
AuthorizedOfficialFirstName: | MARINA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7817615208 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LP0808X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084P0800X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1303287 | 01 | MA | MBHP | OTHER | 1303237 | 01 | MA | MBHP | OTHER | 1304267 | 05 | MA |   | MEDICAID | 1303287 | 05 | MA |   | MEDICAID | 1304267 | 01 | MA | MBHP | OTHER | M18633 | 01 | MA | BCBS | OTHER |