Provider Demographics
NPI:1700215670
Name:NEW ENGLAND REPRODUCTIVE MEDICINE AND SURGERY LLC
Entity Type:Organization
Organization Name:NEW ENGLAND REPRODUCTIVE MEDICINE AND SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-917-3720
Mailing Address - Street 1:22 WEST ST STE 25
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-2677
Mailing Address - Country:US
Mailing Address - Phone:508-917-6720
Mailing Address - Fax:508-917-6721
Practice Address - Street 1:22 WEST ST
Practice Address - Street 2:SUITE 25
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-2622
Practice Address - Country:US
Practice Address - Phone:508-238-8646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226853207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099291AMedicaid