Provider Demographics
NPI:1073647855
Name:FITCHBURG ADULT MEDICINE LLC
Entity Type:Organization
Organization Name:FITCHBURG ADULT MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WOLEJKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-342-6018
Mailing Address - Street 1:76 SUMMER ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-5783
Mailing Address - Country:US
Mailing Address - Phone:978-342-6018
Mailing Address - Fax:978-343-4281
Practice Address - Street 1:76 SUMMER ST
Practice Address - Street 2:SUITE 230
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5783
Practice Address - Country:US
Practice Address - Phone:978-342-6018
Practice Address - Fax:978-343-4281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45633261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0003445OtherMEDICARE PTAN
MA9709029Medicaid
MAA59167Medicare UPIN
MAA55041Medicare UPIN
MAD82840Medicare UPIN
MA9709029Medicaid