Provider Demographics
NPI:1093963381
Name:BURLINGTON MEDICAL GROUP. LLC
Entity Type:Organization
Organization Name:BURLINGTON MEDICAL GROUP. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:TETREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-505-8703
Mailing Address - Street 1:790 BOSTON ROAD
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821
Mailing Address - Country:US
Mailing Address - Phone:781-505-8700
Mailing Address - Fax:781-505-8775
Practice Address - Street 1:790 BOSTON RD
Practice Address - Street 2:
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01821
Practice Address - Country:US
Practice Address - Phone:781-505-8700
Practice Address - Fax:781-505-8775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
MA32439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ11631Medicare UPIN