Provider Demographics
NPI:1891861175
Name:SHAWSHEEN MEDICAL ASSO PC
Entity Type:Organization
Organization Name:SHAWSHEEN MEDICAL ASSO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-475-8886
Mailing Address - Street 1:28 ANDOVER ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810
Mailing Address - Country:US
Mailing Address - Phone:978-475-8989
Mailing Address - Fax:978-475-8886
Practice Address - Street 1:28 ANDOVER ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810
Practice Address - Country:US
Practice Address - Phone:978-475-8989
Practice Address - Fax:978-475-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
54177OtherFULLON
C0193OtherCIGNA
MA9711180Medicaid
MAM17815OtherBCBS
SHAW119181OtherBCBS NH
MA9711180Medicaid