Provider Demographics
NPI:1255470571
Name:WACHUSETT MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:WACHUSETT MEDICAL ASSOCIATES
Other - Org Name:KIMBERLY W EBB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:EBB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-466-2277
Mailing Address - Street 1:50 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453
Mailing Address - Country:US
Mailing Address - Phone:978-466-2277
Mailing Address - Fax:978-466-2282
Practice Address - Street 1:50 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 108
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-466-2277
Practice Address - Fax:978-466-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA151001207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3174671Medicaid
MAA22789Medicare ID - Type Unspecified
MA3174671Medicaid