Provider Demographics
NPI:1790057404
Name:BEACON PRIMARY MEDICINE, INC.
Entity Type:Organization
Organization Name:BEACON PRIMARY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:STANTON
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-794-1463
Mailing Address - Street 1:50 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-2841
Mailing Address - Country:US
Mailing Address - Phone:617-794-1463
Mailing Address - Fax:617-739-1963
Practice Address - Street 1:50 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-2841
Practice Address - Country:US
Practice Address - Phone:617-794-1463
Practice Address - Fax:617-739-1963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78290207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F71191OtherUPIN
MA1225098924OtherNPI
J14325OtherMEDICARE PROVIDER