Provider Demographics
NPI:1679575401
Name:PEDIATRIC ASSOCIATES OF MEDFORD
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF MEDFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:D
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-396-1288
Mailing Address - Street 1:101 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4540
Mailing Address - Country:US
Mailing Address - Phone:781-396-1288
Mailing Address - Fax:781-391-1989
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4540
Practice Address - Country:US
Practice Address - Phone:781-396-1288
Practice Address - Fax:781-391-1989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD88097Medicare UPIN
MAF71087Medicare UPIN
MAG19335Medicare UPIN
MAE19406Medicare UPIN
MAE02014Medicare UPIN
MAE02993Medicare UPIN
MAE02994Medicare UPIN