Basic Information
Provider Information | |||||||||
NPI: | 1760465942 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUGINO | ||||||||
FirstName: | LAVERNE | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
Address2: |   | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370275005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153455400 | ||||||||
FaxNumber: | 8884686603 | ||||||||
Practice Location | |||||||||
Address1: | 119 SUMMIT AVE | ||||||||
Address2: |   | ||||||||
City: | WINTHROP | ||||||||
State: | MA | ||||||||
PostalCode: | 02152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174180478 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2005 | ||||||||
LastUpdateDate: | 12/20/2018 | ||||||||
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 | 207L00000X | 46992 | MA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 2084N0600X | 46992 | MA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
ID | Type | State | Issuer | Description | 6166253 | 05 | MA |   | MEDICAID | 6165362 | 05 | MA |   | MEDICAID | J01021 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | LG58278 | 05 | RI |   | MEDICAID |