Provider Demographics
NPI:1619188281
Name:WEBSTER SQUARE MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:WEBSTER SQUARE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:KEATON
Authorized Official - Last Name:GOLJAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-755-9776
Mailing Address - Street 1:255 PARK AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1953
Mailing Address - Country:US
Mailing Address - Phone:508-755-9776
Mailing Address - Fax:508-793-0715
Practice Address - Street 1:255 PARK AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1953
Practice Address - Country:US
Practice Address - Phone:508-755-9776
Practice Address - Fax:508-793-0715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9768939Medicaid
MAZ096803Medicaid
MA9768939Medicaid
MAQ42225Medicare UPIN
MAA87185Medicare UPIN
MAZ096803Medicaid
MAM15631Medicare ID - Type Unspecified
MAP48371Medicare UPIN
MAB99089Medicare UPIN
MAN01866Medicare ID - Type Unspecified