Provider Demographics
NPI:1164834750
Name:SOUTHBORO MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SOUTHBORO MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LABOSSIERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-460-3297
Mailing Address - Street 1:24 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1215
Mailing Address - Country:US
Mailing Address - Phone:508-481-5500
Mailing Address - Fax:508-460-3025
Practice Address - Street 1:24 NEWTON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1215
Practice Address - Country:US
Practice Address - Phone:508-481-5500
Practice Address - Fax:508-460-3025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-30
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty