Provider Demographics
NPI:1508200908
Name:COHASSET HARBOR ADULT MEDICINE PRACTICE LLC
Entity Type:Organization
Organization Name:COHASSET HARBOR ADULT MEDICINE PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:POMPEO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-383-9422
Mailing Address - Street 1:20 PARKINGWAY
Mailing Address - Street 2:
Mailing Address - City:COHASSET
Mailing Address - State:MA
Mailing Address - Zip Code:02025-1700
Mailing Address - Country:US
Mailing Address - Phone:781-383-9422
Mailing Address - Fax:781-383-8024
Practice Address - Street 1:20 PARKINGWAY
Practice Address - Street 2:
Practice Address - City:COHASSET
Practice Address - State:MA
Practice Address - Zip Code:02025-1700
Practice Address - Country:US
Practice Address - Phone:781-383-9422
Practice Address - Fax:781-383-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30135207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty