Provider Demographics
NPI:1659679793
Name:PREVENTIVE MEDICINE ASSOCIATES
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES
Other - Org Name:ROXBURY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:MM, RHIA
Authorized Official - Phone:413-222-7711
Mailing Address - Street 1:2201 WASHINGTON ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3212
Mailing Address - Country:US
Mailing Address - Phone:617-541-8090
Mailing Address - Fax:617-541-8094
Practice Address - Street 1:2201 WASHINGTON ST
Practice Address - Street 2:SUITE 302
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-3212
Practice Address - Country:US
Practice Address - Phone:617-541-8090
Practice Address - Fax:617-541-8094
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREVENTIVE MEDICINE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-13
Last Update Date:2011-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty