1558316166 NPI number — BOSTON SPINE GROUP, LLC.

Table of content: (NPI 1558316166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558316166 NPI number — BOSTON SPINE GROUP, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOSTON SPINE GROUP, LLC.
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:
1558316166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 4110
Provider Second Line Business Mailing Address:
DEPARTMENT 3110
Provider Business Mailing Address City Name:
WOBURN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01888-4110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-619-0173
Provider Business Mailing Address Fax Number:
781-551-5888

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
299 WASHINGTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02458-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-219-6300
Provider Business Practice Location Address Fax Number:
617-219-6355
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RANCO
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
JUDE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
617-219-6300

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  59668 , 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: M19170 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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