Provider Demographics
NPI:1720005234
Name:DEDHAM MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:DEDHAM MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-278-5540
Mailing Address - Street 1:PO BOX 9120
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02027-9120
Mailing Address - Country:US
Mailing Address - Phone:781-329-1400
Mailing Address - Fax:781-278-5664
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:781-329-1400
Practice Address - Fax:781-278-5664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9766553Medicaid
MA9766561Medicaid
MA9766626Medicaid
MA9766545Medicaid
MA9766596Medicaid
MA9766618Medicaid
MA9766529Medicaid
MA9766537Medicaid
MA9766588Medicaid
MA9766634Medicaid
MA9766545Medicaid
MAM11527Medicare ID - Type Unspecified
MAM11526Medicare ID - Type Unspecified
MAPT0128Medicare ID - Type Unspecified
MA9766626Medicaid
MA9766529Medicaid
MAM11528Medicare ID - Type Unspecified
MA9766561Medicaid
MAM10198Medicare ID - Type Unspecified
MAM11529Medicare ID - Type Unspecified