1902853468 NPI number — HERITAGE MEDICAL GROUP INC.

Table of content: (NPI 1902853468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902853468 NPI number — HERITAGE MEDICAL GROUP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE MEDICAL GROUP 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:
1902853468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 489
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLAND
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02370-0489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-720-1664
Provider Business Mailing Address Fax Number:
207-753-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 HERITAGE PARK
Provider Second Line Business Practice Location Address:
HERITAGE MEDICAL GROUP
Provider Business Practice Location Address City Name:
SANDWICH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-827-7141
Provider Business Practice Location Address Fax Number:
781-834-4292
Provider Enumeration Date:
05/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCANZILLO
Authorized Official First Name:
MAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
781-837-7141

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC0220 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9739050 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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