Provider Demographics
NPI:1720406440
Name:BOSTON MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:BOSTON MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:QUOC
Authorized Official - Middle Name:H
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-735-8451
Mailing Address - Street 1:4901 N.W. 17TH WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309
Mailing Address - Country:US
Mailing Address - Phone:954-229-1969
Mailing Address - Fax:954-229-1994
Practice Address - Street 1:4901 N.W. 17TH WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309
Practice Address - Country:US
Practice Address - Phone:954-229-1969
Practice Address - Fax:954-229-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty