Provider Demographics
NPI:1063689602
Name:MEDIGROUP PC
Entity Type:Organization
Organization Name:MEDIGROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-986-1737
Mailing Address - Street 1:4 FRANK LEARY WAY
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4512
Mailing Address - Country:US
Mailing Address - Phone:781-986-1737
Mailing Address - Fax:866-480-4671
Practice Address - Street 1:20 TREMONT ST
Practice Address - Street 2:SUITE 20
Practice Address - City:DUXBURY
Practice Address - State:MA
Practice Address - Zip Code:02332-5310
Practice Address - Country:US
Practice Address - Phone:781-934-9741
Practice Address - Fax:866-480-4671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASF065069OtherBCBSMA