Provider Demographics
NPI:1346222064
Name:STONEHAM MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:STONEHAM MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-756-7273
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4260
Mailing Address - Country:US
Mailing Address - Phone:781-756-7273
Mailing Address - Fax:781-721-0725
Practice Address - Street 1:88 MONTVALE AVE
Practice Address - Street 2:2
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3643
Practice Address - Country:US
Practice Address - Phone:781-481-9255
Practice Address - Fax:781-481-9257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52067207R00000X
MA152386207R00000X
MA206855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9784993Medicaid
MAM20674Medicare PIN