Provider Demographics
NPI:1568854008
Name:COMMONWEALTH PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:COMMONWEALTH PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-472-6764
Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:SUITE B1
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0908
Mailing Address - Country:US
Mailing Address - Phone:617-472-6764
Mailing Address - Fax:617-770-9933
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:SUITE B1
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0908
Practice Address - Country:US
Practice Address - Phone:617-472-6764
Practice Address - Fax:617-770-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2338832086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS100210913Medicare PIN