Provider Demographics
NPI:1013216738
Name:MEDFORD HEALTHCARE GROUP, LLC
Entity Type:Organization
Organization Name:MEDFORD HEALTHCARE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:I
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-292-5706
Mailing Address - Street 1:26691 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-1421
Mailing Address - Country:US
Mailing Address - Phone:216-292-5706
Mailing Address - Fax:216-292-2273
Practice Address - Street 1:300 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-2311
Practice Address - Country:US
Practice Address - Phone:781-396-4400
Practice Address - Fax:781-396-8348
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SABER HEALTHCARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-21
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0842314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110090142AMedicaid
MA225339Medicare Oscar/Certification