Provider Demographics
NPI:1609071786
Name:ALLSTON PHYSICAL MEDICINE CENTER
Entity Type:Organization
Organization Name:ALLSTON PHYSICAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OGANESOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-783-5783
Mailing Address - Street 1:39 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-2301
Mailing Address - Country:US
Mailing Address - Phone:617-783-5783
Mailing Address - Fax:617-783-1519
Practice Address - Street 1:39 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-2301
Practice Address - Country:US
Practice Address - Phone:617-783-5783
Practice Address - Fax:617-783-1519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3057291Medicaid
MAL-6700Medicare ID - Type UnspecifiedGROUP NUMBER