Provider Demographics
NPI:1710422373
Name:WAYLAND PERSONAL PHYSICIANS PLLC
Entity Type:Organization
Organization Name:WAYLAND PERSONAL PHYSICIANS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-358-3300
Mailing Address - Street 1:109 ANDREW AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-3157
Mailing Address - Country:US
Mailing Address - Phone:508-358-3300
Mailing Address - Fax:508-358-2300
Practice Address - Street 1:109 ANDREW AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-3157
Practice Address - Country:US
Practice Address - Phone:508-358-3300
Practice Address - Fax:508-358-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110120655AMedicaid
MAS100361067Medicare PIN