Provider Demographics
NPI:1669460903
Name:WELL LIFE MEDICAL, PC
Entity Type:Organization
Organization Name:WELL LIFE MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:CMA, CPC
Authorized Official - Phone:978-740-2300
Mailing Address - Street 1:55 HIGHLAND AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2100
Mailing Address - Country:US
Mailing Address - Phone:978-740-2300
Mailing Address - Fax:978-744-3993
Practice Address - Street 1:55 HIGHLAND AVE
Practice Address - Street 2:STE 101
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2100
Practice Address - Country:US
Practice Address - Phone:978-740-2300
Practice Address - Fax:978-744-3993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9779809Medicaid
MAJ13272OtherBCBS
MA076125OtherTUFTS
64871OtherHPHC
MA076125OtherTUFTS
MAM20271Medicare ID - Type Unspecified