Basic Information
Provider Information | |||||||||
NPI: | 1952443244 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMERALD PHYSICIAN SERVICES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 297 NORTH ST STE 221 | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026015133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088627777 | ||||||||
FaxNumber: | 5088627496 | ||||||||
Practice Location | |||||||||
Address1: | 433 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 02601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087784777 | ||||||||
FaxNumber: | 5087719555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2007 | ||||||||
LastUpdateDate: | 08/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONNORS | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5089578540 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 685025 | 01 | MA | USFHP GROUP NUMBER | OTHER | M16587 | 01 | MA | BLUE CROSS GROUP NUMBER | OTHER | 9787208 | 05 | MA |   | MEDICAID | 685025 | 01 | MA | TUFTS INS. GROUP NUMBER | OTHER | CH1554 | 01 |   | RR MEDICARE GROUP NUMBER | OTHER | 2520242 | 01 | MA | AETNA GROUP NUMBER | OTHER |