Provider Demographics
NPI:1639122096
Name:UMASS MEMORIAL RADIOLOGY PHYS SERV
Entity Type:Organization
Organization Name:UMASS MEMORIAL RADIOLOGY PHYS SERV
Other - Org Name:UMASS MEMORIAL PHYSICIANS SERVICE FUND
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:508-334-0311
Mailing Address - Street 1:2527 CRANBERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-1046
Mailing Address - Country:US
Mailing Address - Phone:800-841-5200
Mailing Address - Fax:508-273-1241
Practice Address - Street 1:55 LAKE AVE N # S2-824
Practice Address - Street 2:RADIOLOGY DEPARTMENT ADMINISTRATION
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-7755
Practice Address - Fax:508-856-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9724061Medicaid
MA9724061Medicaid