Basic Information
| Provider Information | |||||||||
| NPI: | 1184636870 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BIOSERENITY DT INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 99 ROSEWOOD DR STE 245 | ||||||||
| Address2: | |||||||||
| City: | DANVERS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019234537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | 9785359778 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 S STATE RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190641232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105436800 | ||||||||
| FaxNumber: | 6105438051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHOCK | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP CLINICAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2145323757 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 0453320000 | 01 | PA | AMERIHEALTH PERS CHOICE | OTHER | 7618325 | 01 | PA | AETNA | OTHER | 0453320000 | 01 | PA | BC/BS PERSONAL CHOICE PPO | OTHER | 0658107000 | 01 | PA | KEYSTONE | OTHER | 0658107000 | 01 | PA | AMERIHEALTH HMO | OTHER |