1750399358 NPI number — WORCESTER FAMILY PRACTICE, INC

Table of content: (NPI 1750399358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750399358 NPI number — WORCESTER FAMILY PRACTICE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORCESTER FAMILY PRACTICE, 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:
1750399358
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:
59 TEMPLE PL
Provider Second Line Business Mailing Address:
SUITE 612
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02111-1307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-264-9764
Provider Business Mailing Address Fax Number:
617-264-9763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 BELMONT ST
Provider Second Line Business Practice Location Address:
UNIT 24
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01605-2964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-770-1602
Provider Business Practice Location Address Fax Number:
508-770-1605
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KISHORE
Authorized Official First Name:
PUNYAMURTULA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
617-738-4640

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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