Provider Demographics
NPI:1760417893
Name:NEPONSET VALLEY SURGICAL PC
Entity Type:Organization
Organization Name:NEPONSET VALLEY SURGICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:NANNERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-828-4030
Mailing Address - Street 1:800 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-2562
Mailing Address - Country:US
Mailing Address - Phone:781-828-4030
Mailing Address - Fax:781-828-7730
Practice Address - Street 1:800 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2562
Practice Address - Country:US
Practice Address - Phone:781-828-4030
Practice Address - Fax:781-828-7730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76851208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
076851OtherTUFTS
8568OtherHARVARD PILGRIM
M18288OtherBCBS
MAJ14582OtherBCBS
MA9717561Medicaid
697329OtherTUFTS
MA3136167Medicaid
M18288OtherBCBS
076851OtherTUFTS
MAJ14582Medicare ID - Type Unspecified