Provider Demographics
NPI:1205854981
Name:MEDWAY COUNTRY MANOR, INC.
Entity Type:Organization
Organization Name:MEDWAY COUNTRY MANOR, INC.
Other - Org Name:GENERATIONS OUTPATIENT WELLNESS & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:508-533-6634
Mailing Address - Street 1:115 HOLLISTON ST
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:MA
Mailing Address - Zip Code:02053-1954
Mailing Address - Country:US
Mailing Address - Phone:508-533-9893
Mailing Address - Fax:508-533-7048
Practice Address - Street 1:115 HOLLISTON ST
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:MA
Practice Address - Zip Code:02053-1954
Practice Address - Country:US
Practice Address - Phone:508-533-9893
Practice Address - Fax:508-533-7048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0840225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0910481Medicaid
Y61422OtherBLUE CROSS BLUE SHIELD
SG0026OtherBLUE CROSS BLUE SHIELD
OG0035OtherBLUE CROSS BLUE SHIELD
MA0910481Medicaid