Provider Demographics
NPI:1871759498
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:MM, RHIA
Authorized Official - Phone:413-222-7711
Mailing Address - Street 1:59 TEMPLE PL
Mailing Address - Street 2:SUITE 664
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1307
Mailing Address - Country:US
Mailing Address - Phone:617-542-7860
Mailing Address - Fax:
Practice Address - Street 1:59 TEMPLE PL
Practice Address - Street 2:SUITE 664
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1307
Practice Address - Country:US
Practice Address - Phone:617-542-7860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREVENTIVE MEDICINE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-03
Last Update Date:2008-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty