Provider Demographics
NPI:1558481879
Name:INTERNAL MEDICAL ASSOCIATES-EBNHC
Entity Type:Organization
Organization Name:INTERNAL MEDICAL ASSOCIATES-EBNHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FANTES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-569-5800
Mailing Address - Street 1:10 GOVE ST
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1920
Mailing Address - Country:US
Mailing Address - Phone:617-569-5800
Mailing Address - Fax:617-568-4780
Practice Address - Street 1:10 GOVE ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1920
Practice Address - Country:US
Practice Address - Phone:617-569-5800
Practice Address - Fax:617-568-4756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM14878Medicare ID - Type Unspecified