Provider Demographics
NPI:1023399425
Name:DR LI'S CLINIC
Entity Type:Organization
Organization Name:DR LI'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:XIANGYANG
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-458-9060
Mailing Address - Street 1:27 EDGEMOOR AVE
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-2210
Mailing Address - Country:US
Mailing Address - Phone:508-458-9060
Mailing Address - Fax:508-458-9060
Practice Address - Street 1:229 E MAIN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2832
Practice Address - Country:US
Practice Address - Phone:508-458-9060
Practice Address - Fax:508-458-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160730101YM0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3205240Medicaid
MAH10302Medicare UPIN
MAA30589Medicare PIN