Provider Demographics
NPI:1114281102
Name:RAD RHEUMATOLOGY AND AUTOIMMUNE DISORDERS
Entity Type:Organization
Organization Name:RAD RHEUMATOLOGY AND AUTOIMMUNE DISORDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FEOKTISTOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-822-2874
Mailing Address - Street 1:675 PARAMOUNT DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-5416
Mailing Address - Country:US
Mailing Address - Phone:508-822-2874
Mailing Address - Fax:508-880-0540
Practice Address - Street 1:675 PARAMOUNT DR
Practice Address - Street 2:SUITE 205
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5416
Practice Address - Country:US
Practice Address - Phone:508-822-2874
Practice Address - Fax:508-880-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211533207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9781510Medicaid
MAM21727Medicare PIN
M21727Medicare PIN