Provider Demographics
NPI:1346713708
Name:SPECIALTY IC MASS LLC
Entity Type:Organization
Organization Name:SPECIALTY IC MASS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTTURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-323-8987
Mailing Address - Street 1:1047 SURF AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2810
Mailing Address - Country:US
Mailing Address - Phone:212-776-9090
Mailing Address - Fax:800-540-1852
Practice Address - Street 1:30 BRAINTREE HILL OFFICE PARK STE 103
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-8751
Practice Address - Country:US
Practice Address - Phone:212-776-9090
Practice Address - Fax:800-540-1852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty