Provider Demographics
NPI:1205215373
Name:MASS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:MASS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HAMID
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:DANESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-888-3147
Mailing Address - Street 1:200 CENTRAL ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2201
Mailing Address - Country:US
Mailing Address - Phone:978-446-7982
Mailing Address - Fax:866-897-3951
Practice Address - Street 1:200 CENTRAL ST
Practice Address - Street 2:SUITE #2
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2201
Practice Address - Country:US
Practice Address - Phone:978-446-7982
Practice Address - Fax:866-897-3951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223435207R00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty