Provider Demographics
NPI:1659722924
Name:CHERRY STREET PHYSICAL MEDICINE PC
Entity Type:Organization
Organization Name:CHERRY STREET PHYSICAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-774-4468
Mailing Address - Street 1:15 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-2880
Mailing Address - Country:US
Mailing Address - Phone:978-774-4468
Mailing Address - Fax:
Practice Address - Street 1:15 CHERRY ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-2880
Practice Address - Country:US
Practice Address - Phone:978-774-4468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA248773208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty