Provider Demographics
NPI:1003911579
Name:NEWTON WELLESLEY PRIMARY CARE P C
Entity Type:Organization
Organization Name:NEWTON WELLESLEY PRIMARY CARE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:HOLGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-235-1224
Mailing Address - Street 1:40 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2173
Mailing Address - Country:US
Mailing Address - Phone:781-943-3000
Mailing Address - Fax:781-943-3001
Practice Address - Street 1:40 WALNUT ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2173
Practice Address - Country:US
Practice Address - Phone:781-943-3000
Practice Address - Fax:781-943-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9777644OtherMASSHEALTH GROUP#
MA607309OtherTUFTS GROUP #
MAM16342OtherBLUESHIELD NEWTON GRP#
MAM20124Medicare PIN
MA9777644OtherMASSHEALTH GROUP#
MAM20317Medicare ID - Type UnspecifiedNEEDHAM OFFICE GROUP #