1932112117 NPI number — DEDHAM MEDICAL ASSOC INC

Table of content: (NPI 1932112117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932112117 NPI number — DEDHAM MEDICAL ASSOC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEDHAM MEDICAL ASSOC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932112117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEDHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02027-9120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-329-1400
Provider Business Mailing Address Fax Number:
781-278-5667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE LYONS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEDHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-329-1400
Provider Business Practice Location Address Fax Number:
781-278-5667
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSO
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
781-278-5540

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9766561 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766626 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766618 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766545 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766634 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766596 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766529 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766553 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766537 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9766588 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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