Provider Demographics
NPI:1417127242
Name:HAVERHILL FAMILY PRACTICE
Entity Type:Organization
Organization Name:HAVERHILL FAMILY PRACTICE
Other - Org Name:HAVERHILL FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-521-6555
Mailing Address - Street 1:62 BROWN ST.
Mailing Address - Street 2:SUITE 404
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830
Mailing Address - Country:US
Mailing Address - Phone:978-521-6555
Mailing Address - Fax:978-521-1236
Practice Address - Street 1:62 BROWN ST
Practice Address - Street 2:SUITE 404
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830
Practice Address - Country:US
Practice Address - Phone:978-521-6555
Practice Address - Fax:978-521-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA27679305S00000X
MA305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service