Provider Demographics
NPI:1124668058
Name:BAHNAN, RITA TONY
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:TONY
Last Name:BAHNAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 BERLIN ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-1125
Mailing Address - Country:US
Mailing Address - Phone:774-452-4522
Mailing Address - Fax:
Practice Address - Street 1:35 BERLIN ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-1125
Practice Address - Country:US
Practice Address - Phone:774-452-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA100024486332Medicaid
MAP986930106OtherBLUE CROSS BLUE SHIELD