Provider Demographics
NPI:1134289432
Name:NEW BOSTON VILLAGE PRIMARY CARE PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:NEW BOSTON VILLAGE PRIMARY CARE PROFESSIONAL CORPORATION
Other - Org Name:NEW BOSTON VILLAGE PRIMARY CARE, P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-674-9300
Mailing Address - Street 1:295 NEW BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-5800
Mailing Address - Country:US
Mailing Address - Phone:508-674-9300
Mailing Address - Fax:
Practice Address - Street 1:295 NEW BOSTON RD
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5800
Practice Address - Country:US
Practice Address - Phone:508-674-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205748207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21782Medicare PIN