UMASS MEMORIAL MEDICAL GROUP, INC.

Provider Demographics

• NPI: 1760445373
• Name: UMASS MEMORIAL MEDICAL GROUP, INC.
• Entity Type: Organization
• Organization Name: UMASS MEMORIAL MEDICAL GROUP, INC.
• Authorized Official - Title/Position: SVP/COO
• Authorized Official - Prefix: MS
• Authorized Official - First Name: GERALDINE
• Authorized Official - Last Name: VAUGHAN
• Authorized Official - Phone: 508-334-0311
• Mailing Address - Street 1: PO BOX 415348
• Mailing Address - City: BOSTON
• Mailing Address - State: MA
• Mailing Address - Zip Code: 02241-5348
• Mailing Address - Country: US
• Mailing Address - Phone: 800-225-8885
• Mailing Address - Fax: 508-334-1977
• Practice Address - Street 1: 55 LAKE AVE N
• Practice Address - Street 2: UMASS MEMORIAL MEDICAL CENTER
• Practice Address - City: WORCESTER
• Practice Address - State: MA
• Practice Address - Zip Code: 01655-0002
• Practice Address - Country: US
• Practice Address - Phone: 508-331-1000
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-04-07
• Last Update Date: 2022-08-22

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	103TC0700X	Behavioral Health & Social Service Providers	Psychologist	Clinical	Group - Multi-Specialty
No	104100000X	Behavioral Health & Social Service Providers	Social Worker		Group - Multi-Specialty
No	204F00000X	Allopathic & Osteopathic Physicians	Transplant Surgery		Group - Multi-Specialty
No	207L00000X	Allopathic & Osteopathic Physicians	Anesthesiology		Group - Multi-Specialty
No	207P00000X	Allopathic & Osteopathic Physicians	Emergency Medicine		Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	207V00000X	Allopathic & Osteopathic Physicians	Obstetrics & Gynecology		Group - Multi-Specialty
No	207X00000X	Allopathic & Osteopathic Physicians	Orthopaedic Surgery		Group - Multi-Specialty
No	207Y00000X	Allopathic & Osteopathic Physicians	Otolaryngology		Group - Multi-Specialty
No	208000000X	Allopathic & Osteopathic Physicians	Pediatrics		Group - Multi-Specialty
No	2084P0800X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Psychiatry	Group - Multi-Specialty
No	208600000X	Allopathic & Osteopathic Physicians	Surgery		Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MA	110000045A	Medicaid
MA	110000045A	Medicaid
MA	M14226	Medicare ID - Type Unspecified
MA	9743227	Medicaid
MA	M12394	Medicare ID - Type Unspecified
MA	M13066	Medicare ID - Type Unspecified
MA	M14752	Medicare ID - Type Unspecified
MA	M12500	Medicare ID - Type Unspecified
MA	M12668	Medicare ID - Type Unspecified
MA	M12395	Medicare PIN
MA	M12401	Medicare ID - Type Unspecified
MA	110000045A	Other	MMIS
MA	M12904	Medicare ID - Type Unspecified
MA	M13412	Medicare ID - Type Unspecified
MA	M13991	Medicare ID - Type Unspecified
MA	M12399	Medicare ID - Type Unspecified
MA	M12409	Medicare ID - Type Unspecified
MA	M15710	Medicare ID - Type Unspecified
MA	M12398	Medicare ID - Type Unspecified
MA	M12400	Medicare ID - Type Unspecified
MA	M14410	Medicare ID - Type Unspecified