Provider Demographics
NPI:1518971860
Name:PRIMARY PHYSICIAN PARTNERS
Entity Type:Organization
Organization Name:PRIMARY PHYSICIAN PARTNERS
Other - Org Name:PRIMARY PHYSICIAN PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-363-7707
Mailing Address - Street 1:PO BOX 2793
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01613-2793
Mailing Address - Country:US
Mailing Address - Phone:508-363-7300
Mailing Address - Fax:508-363-9688
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:SUITE 385N
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-363-7300
Practice Address - Fax:508-363-9688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
MA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3101347Medicaid
41834OtherNETWORK
691558OtherTUFTS
M18243OtherBCBS
MAM21291Medicare PIN
691558OtherTUFTS
M18243OtherBCBS
41834OtherNETWORK