Provider Demographics
NPI:1043364920
Name:COOLIDGE CORNER IMAGING, LLC
Entity type:Organization
Organization Name:COOLIDGE CORNER IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-661-1949
Mailing Address - Street 1:PO BOX 381289
Mailing Address - Street 2:31 SMITH PLACE
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02238-1289
Mailing Address - Country:US
Mailing Address - Phone:617-661-1949
Mailing Address - Fax:617-661-1943
Practice Address - Street 1:356 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2905
Practice Address - Country:US
Practice Address - Phone:617-383-6585
Practice Address - Fax:617-383-6592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA831660OtherTUFTS
MA9750240Medicaid
MAM18932OtherBLUE CROSS BLUE SHIELD
MA9750240Medicaid