Provider Demographics
NPI:1710369368
Name:HAVEN MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:HAVEN MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BASU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-646-9912
Mailing Address - Street 1:86 BAKER AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2132
Mailing Address - Country:US
Mailing Address - Phone:978-391-9275
Mailing Address - Fax:
Practice Address - Street 1:86 BAKER AVENUE EXT
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2132
Practice Address - Country:US
Practice Address - Phone:978-391-9275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty