Provider Demographics
NPI:1760155584
Name:UMASS MEMORIAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:UMASS MEMORIAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOOLDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-334-8890
Mailing Address - Street 1:281 LINCOLN STREET
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2138
Mailing Address - Country:US
Mailing Address - Phone:508-334-8890
Mailing Address - Fax:
Practice Address - Street 1:70 EAST ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-4597
Practice Address - Country:US
Practice Address - Phone:978-687-0151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UMASS MEMORIAL MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty