Provider Demographics
NPI:1861448797
Name:MASSACHUSETTS MOBILE PET PC
Entity Type:Organization
Organization Name:MASSACHUSETTS MOBILE PET PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-687-2321
Mailing Address - Street 1:354 MERRIMACK ST
Mailing Address - Street 2:ENTRANCE D
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1754
Mailing Address - Country:US
Mailing Address - Phone:978-687-8187
Mailing Address - Fax:978-687-8185
Practice Address - Street 1:25 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3867
Practice Address - Country:US
Practice Address - Phone:978-689-4738
Practice Address - Fax:978-682-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44-0373261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
3137889OtherAETNA
706023OtherHARVARD PILGRIM
MA972781Medicaid
0032507OtherNEIGHBORHOOD HEALTH
696200OtherTUFTS
M18139OtherBLUE CROSS OF MA
MA972781Medicaid