1104813476 NPI number — WOBURN MEDICAL ASSOCIATES PC

Table of content: (NPI 1104813476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104813476 NPI number — WOBURN MEDICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOBURN MEDICAL ASSOCIATES PC
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:
1104813476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 WARREN AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01801-4979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-933-1198
Provider Business Mailing Address Fax Number:
781-933-9246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 WARREN AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
WOBURN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01801-4979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-933-1198
Provider Business Practice Location Address Fax Number:
781-933-9246
Provider Enumeration Date:
10/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ALBANESE
Authorized Official First Name:
SALVADOR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-933-1198

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 600386 . This is a "TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: M15271 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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