Provider Demographics
NPI:1871571737
Name:NEW BOSTON MEDICAL GROUP LLP
Entity type:Organization
Organization Name:NEW BOSTON MEDICAL GROUP LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:STRATTON
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-628-0422
Mailing Address - Street 1:114 W US HIGHWAY 82
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:TX
Mailing Address - Zip Code:75570-2804
Mailing Address - Country:US
Mailing Address - Phone:903-628-0422
Mailing Address - Fax:903-628-0448
Practice Address - Street 1:114 W US HIGHWAY 82
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:TX
Practice Address - Zip Code:75570-2804
Practice Address - Country:US
Practice Address - Phone:903-628-0422
Practice Address - Fax:903-628-0448
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW BOSTON MEDICAL GROUP LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-02
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK90258174400000X
TXK0219174400000X
TXPA03545363AM0700X
TX660180363L00000X
TX564395363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165646401Medicaid
TX00851WMedicare UPIN
TX165646401Medicaid