Provider Demographics
NPI:1114979580
Name:THE MCLEAN HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:THE MCLEAN HOSPITAL CORPORATION
Other - Org Name:MCLEAN PROFESSIONAL PRACTICE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-855-2367
Mailing Address - Street 1:P.O. BOX 5-0397
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01815-0397
Mailing Address - Country:US
Mailing Address - Phone:617-855-2183
Mailing Address - Fax:617-855-3745
Practice Address - Street 1:115 MILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1041
Practice Address - Country:US
Practice Address - Phone:617-855-2183
Practice Address - Fax:617-855-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9778705Medicaid
MAM16400OtherBC/BS
MA1201174Medicaid
MAW10374OtherBC/BS
MA224007Medicare ID - Type Unspecified
MAM20904Medicare ID - Type Unspecified
MA1201174Medicaid