Provider Demographics
NPI:1376782466
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:NEUROSCIENCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:MM, RHIA
Authorized Official - Phone:413-222-7711
Mailing Address - Street 1:1842 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-1930
Mailing Address - Country:US
Mailing Address - Phone:617-278-1478
Mailing Address - Fax:617-278-1471
Practice Address - Street 1:1842 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-1930
Practice Address - Country:US
Practice Address - Phone:617-278-1478
Practice Address - Fax:617-278-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty