Provider Demographics
NPI:1609026871
Name:LONDON MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LONDON MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-277-8770
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02030-0187
Mailing Address - Country:US
Mailing Address - Phone:508-785-0899
Mailing Address - Fax:
Practice Address - Street 1:17 OAK ST
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-2470
Practice Address - Country:US
Practice Address - Phone:781-559-0540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9742191Medicaid
MAM19587OtherBCBS
MA1609026871OtherTUFTS
MAM19587OtherBCBS