Provider Demographics
NPI:1053855247
Name:URGENT CARE OF MEDFORD, LLC
Entity Type:Organization
Organization Name:URGENT CARE OF MEDFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER/CMO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENKARE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:203-616-4440
Mailing Address - Street 1:2928 MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1007
Mailing Address - Country:US
Mailing Address - Phone:860-430-1246
Mailing Address - Fax:203-905-6824
Practice Address - Street 1:4110 MYSTIC VALLEY PKWY
Practice Address - Street 2:SUITE 2
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-6931
Practice Address - Country:US
Practice Address - Phone:781-874-9399
Practice Address - Fax:781-874-9275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS100303504Medicare PIN