Provider Demographics
NPI:1558330548
Name:COMMONWEALTH SURGICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:COMMONWEALTH SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:YANNALFO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-279-1123
Mailing Address - Street 1:91 MONTVALE AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3623
Mailing Address - Country:US
Mailing Address - Phone:781-279-1123
Mailing Address - Fax:781-438-3034
Practice Address - Street 1:91 MONTVALE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3623
Practice Address - Country:US
Practice Address - Phone:781-279-1123
Practice Address - Fax:781-438-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9712194Medicaid
MAM17876OtherBCBS
MAM21041Medicare ID - Type Unspecified