Basic Information
| Provider Information | |||||||||
| NPI: | 1710962329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZEULI | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 95 WASHINGTON ST | ||||||||
| Address2: | STE 462 | ||||||||
| City: | CANTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818287920 | ||||||||
| FaxNumber: | 7818287951 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 WASHINGTON ST | ||||||||
| Address2: | STE 462 | ||||||||
| City: | CANTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818287920 | ||||||||
| FaxNumber: | 7818287951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5662 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0386685 | 05 | MA | MEDICAID |