Provider Demographics
NPI:1174827745
Name:DEDHAM MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:DEDHAM MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-278-5512
Mailing Address - Street 1:PO BOX 9120
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02027-9120
Mailing Address - Country:US
Mailing Address - Phone:781-329-1400
Mailing Address - Fax:
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:781-329-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEDHAM MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2881291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM11529Medicare PIN
MAM11527Medicare PIN