Provider Demographics
NPI:1760957609
Name:SQUARE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SQUARE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:GERSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-916-5069
Mailing Address - Street 1:124 WATERTOWN ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2599
Mailing Address - Country:US
Mailing Address - Phone:617-916-5069
Mailing Address - Fax:
Practice Address - Street 1:124 WATERTOWN ST STE 2D
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2599
Practice Address - Country:US
Practice Address - Phone:617-916-5069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)