Provider Demographics
NPI:1790957470
Name:PENTUCKET MEDICAL RADIOLOGY
Entity Type:Organization
Organization Name:PENTUCKET MEDICAL RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-521-3200
Mailing Address - Street 1:1 PARKWAY
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-6278
Mailing Address - Country:US
Mailing Address - Phone:978-521-3260
Mailing Address - Fax:978-469-5378
Practice Address - Street 1:1 PARKWAY
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-6278
Practice Address - Country:US
Practice Address - Phone:978-521-3260
Practice Address - Fax:978-469-5378
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENTUCKET MEDICAL ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-02
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA09570261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0039516OtherNEIGHBORHOOD HEALTH PLAN