Provider Demographics
NPI:1700191889
Name:COOLIDGE CORNER IMAGING
Entity Type:Organization
Organization Name:COOLIDGE CORNER IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARIANACCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-383-6585
Mailing Address - Street 1:356 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2905
Mailing Address - Country:US
Mailing Address - Phone:617-383-6585
Mailing Address - Fax:617-383-6592
Practice Address - Street 1:356 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2905
Practice Address - Country:US
Practice Address - Phone:617-383-6585
Practice Address - Fax:617-383-6592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9750240Medicaid
M21550Medicare PIN